Influence of Pre- and Intraoperative Local Anaesthetic in Strabismus Surgery under General Anaesthesia in Adults.

BACKGROUND: As studies have shown a reduction in the occurrence of the oculocardiac reflex with the addition of local anaesthesia, we changed our care regime accordingly a few years ago. To promote and establish better patient care, we retrospectively analysed the files of our patients who underwent strabismus surgery from 2013 to 2021 in order to compare strabismus surgery under general anaesthesia with and without local anaesthetics in a routine clinical setting. PATIENTS AND METHODS: Data from 238 adult patients who had undergone strabismus surgery could be extracted from the files: G1: n = 102, only general anaesthesia; G2: n = 136, preoperative application of tetracaine eye drops and intraoperative subtenon lidocaine/levobupivacaine in addition to general anaesthesia. We compared the two groups in regard to the frequency of oculocardiac reflex, the amount of atropine needed to treat, as well as the amount of antiemetic and analgesic medication given, and time spent in the recovery room. RESULTS: Mean age of G1 was 50 years and 52 years in G2. There was no significant difference between the kind of surgeries (recessions/resections), the number of patients who had undergone a reoperation, or the duration of the operations. Adding local anaesthetics resulted in significantly less occurrence of oculocardiac reflex (p = 0.009), a reduction in the need for atropine, analgesic, or antiemetic medication, as well as reduced time in the recovery room. CONCLUSION: As this increases patient safety and comfort and is cost-effective (less time in the recovery room), we recommend adding perioperative local anaesthesia to strabismus surgery performed under general anaesthesia.

Retrospective Comparison of the Myopia Master and the Lenstar LS900 Axial Length Measurements in Children with Myopia.

BACKGROUND: This study is a retrospective analysis to compare ocular biometry measurements of axial length in children with myopia using Myopia Master (OCULUS, Wetzlar, Germany) and Lenstar LS900 (HAAG-STREIT AG, Köniz, Switzerland). PATIENTS AND METHODS: Axial length measurements obtained with both instruments within a 3-week period were collected retrospectively. Measurements were visualized with a Bland-Altman plot. For statistical evaluation, a paired t-test was applied, and the Pearson correlation coefficient (r) was established. RESULTS: Sixty-one eyes from 31 myopic patients (59% male, 41% female) with a mean age of 11.34 ± 3.25 years (range: 6 - 18 years) were identified. Mean axial length was 24.7 mm (SD 1.29) with the Myopia Master and 24.69 mm (SD 1.30) with the Lenstar LS900 (Pearson correlation: r = 0.9991). The average difference of the axial length measurement between the two biometers was 0.00 064 mm ± 0.056 SD (p = 0.9293). CONCLUSION: The axial length measured by Myopia Master and Lenstar LS900 did not differ significantly. Thus, previous values obtained with the Lenstar LS900 can be applied to assess myopia progression.

The Influence of Age on Eye Movements during Reading in Early Elementary School Children.

PURPOSE: Eye movement disorders have been observed in many eye diseases, such as amblyopia and developmental dyslexia. The detection of pathological eye movement behaviour is difficult and requires more data for comparison. Therefore, the main purpose of this study was to evaluate the influence of age, school level, gender, and mother tongue on eye movements while reading. METHODS: One hundred and twenty-seven normally sighted children aged 7 - 12 were recruited from grades 2 - 5. The children were asked to read aloud two texts of The New International Reading Speed Text (IReST) of similar difficulty. Eye movements while reading were recorded by eyetracking technology (SMI RED 250, SensoMotoric Instruments, Teltow, Germany). The eye movement parameters were obtained from 118 children, and reading speed (words/minute), number of saccades, number of fixations, reading errors, and influence of school grade were analyzed. RESULTS: We showed a significant influence of age in all eye movement parameters. The main finding of this study is that younger children performed more saccades, a higher number of fixations per word, and more reading errors while taking more time to read the text than older children in higher grades. In early grades, non-native German speakers read more slowly and performed more saccades and fixations, but no more differences were seen by grade 5. Overall, there was no significant influence of gender or school system on reading parameters. CONCLUSION: This study highlights the need for an age-appropriate normative database for eye movements during reading.

Evaluation of the Therapeutic Efficacy of Perceptual Learning Using the Bartimeus Training Program in the Clinic as an Additional Therapy to Glasses or Patching.

BACKGROUND: The Bartimeus training program (BT) is a perceptual learning task that consists of a drawing assignment performed in 12 sessions of 30 minutes duration. Here we aim to retrospectively assess visual improvement in children who underwent BT and in whom visual acuity had not improved by glasses or patching in relation to patient age and diagnosis. MATERIAL AND METHODS: Retrospective chart analysis of patients who had undergone BT at our institution after consent. Visual acuity prior to and following BT was analyzed, as were diagnosis and age at BT. RESULTS: Thirteen patients (20 eyes) with a mean age of 7 years (range: 3.9 - 10.75) were included. Overall acuity (LogMar) improved in 75%. Six patients aged 6.5 - 7.5 years had a mean improvement of 1.4 lines. The greatest improvement (5 lines crowding acuity) was seen in a 9-year-old with recent onset amblyopia due to corneal scarring. Two patients aged 6 years with deprivation amblyopia following surgery of a congenital cataract and one 5-year-old with retinitis pigmentosa did not benefit from BT. CONCLUSIONS: BT is a cheap noninvasive method that may help improve visual outcomes. Further studies with larger numbers are needed to assess optimal indication, timing, and length of treatment.

Strabismus Surgery: A Retrospective Comparison of Different Postoperative Treatment Regimes to Prevent Infections.

BACKGROUND: As studies have shown postsurgical polyvidone-iodine to be at least equal to postsurgical topical antibiotics, our postsurgical care regime was adjusted accordingly in 2017. Here, we retrospectively compared the postsurgical infection rate in patients who underwent strabismus surgery prior to and following this change in regimen in a routine clinical setting. PATIENTS AND METHODS: In this retrospective and explorative study, data from 162 adult patients who had undergone strabismus surgery was extracted from files: 98 patients who had received topical gentamycin in a combination ointment with steroid (postsurgery) followed by 1 week of topical gentamycin with nonsteroidal antiphlogistic eye drops for 1 week (group 1) and 64 who had received polyvidone-iodine once immediately postsurgically instead. We compared both groups' postsurgical healing period regarding occurrence of bacterial conjunctival infection and conjunctival swelling and redness as well as other complications. Data were extracted from the entries of the routine follow-up dates on postsurgical days 1, 7, and at 3 months. RESULTS: Mean age of group 1 was 49 years and 51 years in group 2. There was no significant difference between the kind of surgeries (recessions/resections) or the number of patients who had undergone a reoperation. There was no significant difference between the groups for any of the endpoints analyzed at any of the three regular follow-up dates. From group 1, 12.04% and from of group 2, 6.25% showed bacterial conjunctivitis 1 week postsurgery. There was no endophthalmitis. CONCLUSION: Topical polyvidone-iodine given once at the end of strabismus surgery is a good alternative to topical antibiotics with a comparable healing progress. It carries a comparable risk of infection as seen with a 1-week course of topical antibiotics. The advantages are less manipulation of the eye, no bacterial resistance caused, and cost efficiency. In addition, the lack of anti-inflammatories given in group 2 did not pose a disadvantage.

[Therapy of Hemifacial Spasm with Botulinum Toxin: an Update]. / Botulinumtoxin ­ Therapie des Spasmus hemifacialis: Ein Update.

Injections of botulinum toxin can be viewed by now as the therapy of choice in treating hemifacial spasm (HFS). Each of the three botulinum toxin-A preparations have been approved for this indication in Germany. HFS is a frequent disease characterized by involuntary contractions of the muscles of one half of the face innervated by the facial nerve. The symptoms can be either tonic or clonic, intermittant or permanent. Diagnosis is based purely on clinical observation. A magnetic resonance imagingof the skull is appropriate to demonstrate nerve-vessel contact as most frequent cause and to exclude other pathologies.

Establishing Prediction Intervals for the SpeedWheel Acuity Test in Adults and Children.

BACKGROUND: The SpeedWheel (SW) test is an objective test of visual acuity (VA) using suppression of the optokinetic nystagmus (OKN). Here, we established prediction intervals of the SW measures compared to Snellen acuity in adults and children. SUBJECTS AND METHODS: In this prospective, single center study, subjects aged at least 4 years underwent testing of VA with SW, Landolt-C, and Tumbling-E symbols (Freiburg acuity test: FrACT-C, FrACT-E). Prediction intervals were established for SW compared to FrACT-C or -E and for FrACT-E compared to FrACT-C. Mixed linear effect models were applied for statistical analysis. RESULTS: From 241 subjects, 471 eyes were included: median age 36 years, range 4 - 88 years, 43.6% male, 56.4% female. Eyes included were either healthy or had various underlying ophthalmic conditions. Prediction intervals for SW to estimate FrACT-C or -E acuity showed a similar range compared to the prediction interval of FrACT-C for the estimation of FrACT-E acuity. For each acuity step, there was no influence of age. Up to an SW acuity of 0.7 logMAR, 80% of the subjects had a FrACT-C acuity that was at most 1.6 logMAR lines below, and for an SW acuity of 1.0 logMAR, FrACT-C acuity was not worse than 4 logMAR lines. Prediction intervals for eyes with refractive error, cataract, visual field loss and retinal disease did not differ significantly from healthy eyes in contrast to eyes with amblyopia or multiple ophthalmic disorders. SW correlated well to FrACT tests and results of a previous study fell within our prediction estimates. CONCLUSION: Our prediction intervals for SW acuity may be used to estimate Snellen acuity (FrACT-C and -E) in the clinic in adults and children unable to cooperate in other acuity testing.

Slowing Down Myopia Progression with Contact Lenses - Everyday Cases from the Clinic.

BACKGROUND: An estimated 49.8% of the world population will be myopic by 2050. Multifocal contact lenses (MFCLs) and orthokeratology (OK) reduce peripheral retinal hyperopic defocus, which animal studies have shown to positively impact eye growth. MFCLs are expected to slow myopic progression by 20 - 50% and OK by 30 - 60%, making them valuable therapeutic tools. In view of the guidelines for myopia management published by the International Myopia Institute in 2019, the aim of this retrospective data analysis of a tertiary care center was to review past experience with OK and MFCLs for myopia control and gain information to update current practice. PATIENTS AND METHODS: The contact lens (CL) database of the Eye Clinic of the University Hospital of Basel was searched with the label "myopia progression" between January 2012 - 2020. Patients were included if they gave informed consent, were younger than 19 years old at baseline, and had no ocular comorbidities that could potentially compromise vision. Primary outcomes were progression of spherical equivalent refraction for MFCL patients and progression of axial length (AL) for the OK group, comparing with historical data from OK trials. Secondary outcomes were the presence of risk factors for myopia, age, refractive error at baseline, follow-up duration, and adverse effects during therapy. RESULTS: Twenty-one patients could be included, with a mean age of 12.80 ± 3.32 years (y) at baseline. The majority of patients were older than 12 years and already myopic (- 3.89 ± 2.30 diopters) when control treatment was started. Overall, follow-up ranged from 0.08 to 6.33 years (2.03 ± 1.66 y). In the patients treated with MFCLs, myopia control improved significantly when patients changed from spectacles to MFCLs. In the OK group, 14% dropped out during the first year and 2 patients had multiple AL measurements during therapy, which showed a slower growth of AL when compared to other OK trials and controls with spectacles. There were two cases of non-severe keratitis. Environmental risk factors had not been documented and only 48% of clinical records had a documented family risk assessment. CONCLUSION: Patients showed a slower myopia progression under MFCLs or OK, which supports their role as a treatment option in myopia management. In this regard, AL measurement is an important additional parameter to be included in the assessment of myopia progression in clinical practice. Identification of children at risk of developing high/pathologic myopia (family history, environmental risk factors) needs to improve so that the first stages of myopic shift can be recognized and targeted. Changes in lifestyle should be actively encouraged, especially when the impact of decreases in outdoor time secondary to COVID-19 is yet to become clear.

Comparing Botulinum Toxin Injections with Extraocular Muscle Surgery in Toddlers with Esotropia: A Retrospective Analysis.

BACKGROUND: In toddlers with esotropia, early alignment of the visual axes either with extraocular muscle surgery (EOMS) or botulinum toxin injections (BTIs) into both medial rectus muscles may result in improved depth perception. We compared the outcome of BTIs with EOMS in toddlers in order to gain further insight into the advantages and disadvantages of either method. PATIENTS AND METHODS: In this retrospective study, our encrypted database was searched for toddlers with esotropia aged 35 months or younger at the time of initial treatment with either BTIs or EOMS and who had a follow-up of at least 2 years. We analyzed the angle of deviation, dose effect (DE), and binocularity as well as the number of interventions. RESULTS: We identified 26 toddlers who received their first treatment for esotropia within the first 35 months of life: 16 with BTIs (9 males, 7 females) and 10 with EOMS (3 males, 7 females). Mean follow-up was considerably longer in the EOMS (87.7 months) than in the BTI group (35.7 months). Age at first intervention was 22.8 months in the BTI and 24.1 months in the EOMS group, and each toddler wore its full cycloplegic refraction. Mean angle at treatment was 41.25 prism diopters (PD) in the BTI compared to 52.9 PD in the EOMS group. The BTI group received an average of 1.68 BTIs, with a mean dosage of 14.5 IU Botox and a mean DE (mDE) of 1.8 PD/IU. In the EOMS group, the average number of surgeries was 1.4, with a mean dosage of 16.85 mm and a mDE of 3.14 PD/mm surgery. Some degree of binocularity could be observed in 9 (56%) of the BTI (5 × Bagolini positive, 2 × 550″, 2 × 220″) and in 4 (40%) of the EOMS group (2 × 3600″, 1 × 550″, 1 × 300″). By the end of the BTI group follow-up, four toddlers electively underwent EOMS rather than a 3rd BTI (followed by a 3rd BTI in 1), which resulted in the appearance of measurable binocularity in all four (1 × Bagolini positive, 1 × 220″, 1 × 200″, 1 × 60″). CONCLUSIONS: Our results show that BTIs are a viable treatment alternative in early esotropia. Even if EOMS is ultimately required, some binocularity may develop as the visual axes are aligned for some time in the sensitive phase owing to the effects of Botox. Moreover, less surgical dosage is needed than would have otherwise been necessary to treat the original angle of deviation. BTIs are faster, less invasive, and present as an effective alternative when patient compliance is too low to reliably measure the angle of deviation, which is essential for the planning of EOMS.

Establishing an Objective Measurement of Visual Acuity with a Computerised Optokinetic Nystagmus Suppression Test.

OBJECTIVE: Investigating the correlation between subjective and objective VA (visual acuity) elicited with a newly developed computerised optokinetic nystagmus (OKN) suppression test ("SpeedWheel") in adults. METHODS: SpeedWheel presented alternating black/white stripes moving horizontally across a LED screen. Seven VA steps were induced with Bangerter filters placed onto spectacle frames. Magnified eye movements were projected from infrared cameras inside the frames and displayed onto a smartphone. Dots whose size increased in logarithmic steps were superimposed to suppress OKN. Suppression of OKN resulted in the SpeedWheel acuity which was then correlated to Snellen acuity as measured with the Freiburg Acuity test. RESULTS: 28 eyes from 14 individuals were tested. FrACT-E correlated well to SpeedWheel (r: 0.89; p < 0.001). Snellen acuity was never lower than 0.14 LogMAR of SpeedWheel values. Bangerter filters showed greater mean difference to both methods indicating that this filter is not as predictable as suggested by the filter value. CONCLUSION: SpeedWheel offers a fast (< 80 sec) and reliable alternative option to measure objective VA.

Strabismus Surgery of Consecutive Exotropia.

PURPOSE: The purpose of this study was to determine the surgical outcome, dose-effect (DE), and degree of binocularity in patients undergoing surgery for consecutive exotropia following initial surgery of esotropia. PATIENTS/METHODS: Twenty-one patients were identified. We analyzed the mean angle of deviation pre- and postoperatively as measured with the alternate prism cover test, DE, and binocularity. RESULTS: All patients had had previous strabismus surgery. The surgery for consecutive exotropia had been performed at a mean age of 35.92 ± 18.26 years. In 19 of these patients, surgery of consecutive exotropia involved at least one previously operated extraocular muscle, and the mean interval to the previous surgery was 25.67 ± 16.14 years. The mean angle of deviation (DE) at distance and in the primary position was - 33.43 ± 12.75 prism diopters (PD) preoperatively, + 0.76 ± 7.91 PD 1 week after surgery, and - 7.24 ± 12.14 PD 3 months after surgery. The mean DE was 3.58 ± 1.53 mm/PD at 1 week and 2.70 ± 1.78 mm/PD at 3 months post-surgery. Postoperatively, 62% patients had a binocularity of at least Bagolini positive, 33% had either a positive TNO or Titmus Test, and 24% were Lang I positive (550″). CONCLUSION: Performing strabismus surgery with consecutive exotropia results in restoration of some binocularity in a large number of patients, even in adults, and should be considered as a possibility. The dose-effect is comparable to conventional surgery of exotropia.

Feasibility of Eye Movement Recordings with the SMI Tracking Bar in 10- to 11-Year-Old Children Performing a Reading Task.

INTRODUCTION: Eye movements during reading can be impaired in amblyopia, developmental dyslexia, reduced visual acuity, or visual field defects. To detect pathology, normative values are important for comparison. In healthy children, there is sparse data on eye movements during reading. Therefore, the aim of this study was to, in a first step, explore the feasibility of applying the SMI RED eye tracker bar to record eye movements in 10- and 11-year-old children while reading a text. MATERIALS AND METHODS: Thirty-three (19 aged 10 years, 14 aged 11 years) normally sighted children attending a primary school in Switzerland participated in our study. Visual acuity, the Lang test, and the cover test were performed as a screening for ophthalmologic pathology that might influence the results. Eye movements were recorded with the SMI RED eye tracker bar while the child read aloud two texts from the International Reading Speed Test (IReST), presented on a laptop. Both texts were in German with an equal level of difficulty and were presented in a randomized order. Reading speed (words/minute), number of saccades, number of fixations, and reading errors (mistakes in the reading) were evaluated. RESULTS: Screening did not reveal pathology other than refractive errors and children had full corrected visual acuity. Eye movements could be obtained in all but six children where the reflection of the glasses worn prevented a good pupil recording with the tracker. Younger children performed more saccades per word with a mean of 1.41 (SD 0.39) at 10 years of age versus 1.10 (SD 0.21) at 11 years of age. The number of fixations per word was also higher in younger children (mean: 1.63 [SD 0.37]) than in 11-year-old children (mean: 1.32 [SD 0.33]). Ten-year-old children seem to analyze a text in smaller units than 11-year-olds. Thus, 10-year-old children took more time to complete the reading task than the 11-year-olds (mean: 88.8 s [SD 24.1] versus 84.4 s [SD 15.1]). In addition, 10-year-old children made more reading errors compared to 11-year-olds (mean: 4.47 [SD 2.95] versus 2.28 [SD 1.72]). CONCLUSION: It is feasible to record eye movements in children aged 10 - 11, albeit this is more difficult when glasses are worn. As parameters change with age, further data is needed for a representative evaluation regarding eye movements during reading in children of different age groups. The information gained may offer help in recognizing reading difficulties and monitoring of treatment effects.

Comparing Three Different Contrast Sensitivity Tests in Adults and in Children with and without Amblyopia.

BACKGROUND: Tests of contrast sensitivity (CS) are not routinely performed in the clinic, although CS is reduced in many conditions, such as amblyopia or glaucoma. This may be due to perceived time constraints or unaffordability of equipment. PATIENTS AND METHODS: Monocular CS functions obtained with the FACT, CSV 1000E, and Lea Symbols were compared in 19 healthy subjects aged 24 - 78 years and 24 subjects aged 5 - 16 years, 9 of whom had amblyopia. RESULTS: CS functions could be obtained with all three tests. The tests were equally comfortable for young and adult patients, and took less than 5 minutes to perform (one eye). All measured CSs at 3, 6, 12, and 18 cycles per degree (cpd), but the FACT included 1.5 cpd. LINEAR MIXED EFFECT MODELS: were performed. While there was no significant difference at low spatial frequencies, the Lea CS test showed a ceiling effect in that range, while the FACT showed a floor effect at high spatial frequencies. CS in amblyopic children did not differ between the contralateral and the amblyopic eye. Overall, amblyopic eyes had lower CS values than the control eyes and CS did not correlate significantly to visual acuity at distance. CONCLUSION: All three CS tests could be usefully applied in the clinic in adults as well as children over the age of 4 years. Only the CSV 1000E exhibited neither a ceiling nor a floor effect. This was also the fastest test. In children with amblyopia, CS testing offers additional information on visual function. In contrast to previous reports, we did not find that the CSV and FACT are interchangeable.

Plication versus Resection in Horizontal Strabismus Surgery.

BACKGROUND: To compare two commonly used strengthening procedures in strabismus surgery: plication and resection of the extraocular muscle (EOM). PATIENTS AND METHODS: From an anonymous databank of strabismus surgeries, performed at the University Eye Hospital Basel, patients with a horizontal strabismus surgery, consisting of a recession combined with either plication or resection of the antagonist and a follow-up of at least 3 months, were included. Exclusion criteria were previous eye surgeries, binocular surgeries, and simultaneous surgery of oblique or vertical EOM. Pre- and postoperative angles were measured using the alternating prism cover test during fixation at distance. RESULTS: Fifty-nine patients met the criteria and were matched according to the angle at baseline in the recession/plication group, resulting in 12 resection/recession and 12 plication/recession patients. There was no significant difference in the number of eso- and exodeviations, age at surgery, or gender between the groups. Mean difference between plication and resection was 1.2 PD at 1 week (p = 0.72) and 1.7 PD at 3 months (p = 0.61). A separate analysis for eso- and exodeviations showed no significant difference between recession/plication and recession/resection at 1 week or 3 months (p value side effect = 0.59; resection vs. plication at 1 week p = 0.68; resection vs. plication at 3 months: p = 0.57). The overall dose effect (SD) was 2.13 PD (0.88)/mm in the recession/plication group and 2.51 PD (0.81)/mm in the recession/resection group after 1 week (p = 0.331). After 3 months, the mean dose effect was 1.85 PD (1.06)/mm in the recession/plication group and 2.09 PD (1.12)/mm in the recession/resection group (p = 0.611). DISCUSSION: Our findings show that recession/plication is a valid alternative to recession/resection in horizontal strabismus without the need to cut the muscle, as we saw no difference in surgical effectiveness in either eso- or exodeviations at 1 week or at 3 months.

Novel PDE6B Mutation Presenting with Retinitis Pigmentosa - A Case Series of Three Patients.

BACKGROUND: Retinitis pigmentosa (RP) affects 2.5 million people worldwide. Increased identification of causative gene defects and the increasing possibility of treatment necessitates better knowledge of phenotype-genotype correlations to help identify patients who would benefit from targeted gene therapy and improve patients' care. Here, we report on three RP patients with mutations in the PDE6Β Gene that have not been described previously. HISTORY AND SIGNS: Three patients with a PDE6Β mutation were identified: 1. A 30-year-old male with a homozygotous mutation (c.[2351dupA],[2351dupA], p.[Q785Gfs*20],[Q785Gfs*20]) who was followed for 8 years. 2. A 54-year-old Caucasian woman with a heterozygous mutation [p.(K611Nfs*6), p.(Q567*)] who was followed for 40 years. 3. A 46-year-old Caucasian male [p.(E271K), p.(R627_E631del)]. All had noted an onset in childhood and complained of night blindness and photophobia. Typical bone spiculae were seen, and peripheral visual fields were progressively affected in all patients. Ganzfeld-ERG showed typical signs of rod-cone dystrophy. Patients 1 and 2 underwent cataract surgery at ages 27 and 36 years with an improvement in vision, while patient 3 had not developed a cataract at age 54. CONCLUSIONS: In children complaining of night blindness, a PDE6Β-associated RP needs to be taken into consideration. Apart from helping patients with optical aids, such as polarizing filters or magnification, a specific diagnosis is especially important in view of emerging genetic treatment options. In particular, in RP patients with a PDE6Β mutation, a phase I/II study is currently ongoing (https://clinicaltrials.gov/ct2/show/NCT03328130).

[Therapy of Hemifacial Spasm with Botulinum Toxin]. / Therapie des Spasmus hemifacialis mit Botulinumtoxin.

Hemifacial spasm (HFS) is a frequent disorder characterized by involuntary contractions of those muscles innervated by the facialis nerve on one side of the face. The symptoms can appear as tonic or clonic, intermittent or permanent. Diagnosis is based purely on clinical observation. Differential diagnosis should rely on cranial MRI, which can demonstrate a pathological contact between the nerves and vessels and exclude alternative causation. Often, the symptoms are not marked so that therapy may not be necessary. The therapy of choice is an injection of botulinum toxin to reduce the underlying pathological activity. As an alternative, decompression operation according to Jannetta can be considered, although it is frequently rejected by patients.

Botulinum Toxin for the Treatment of Cyclic Strabismus in Children: Three Case Reports.

Cyclic strabismus is a rare disease of unknown origin. If untreated, it leads to manifest strabismus with the risk of amblyopia in children. Treatment is generally surgical. Here we report on three children in whom cyclic esotropia was successfully treated with one bimedial injection of 5 IU Botox®. All patients remained orthotropic with good stereo functions at the last follow-ups at 16, 11, and 8 months. Botulinum toxin offered a minimally invasive treatment option in these patients.