Nonpharmacologic Treatment of Chronic Constipation.

Functional constipation is a common clinical diagnosis that affects approximately 14% of the world's population. Non-pharmacological therapies often represent the initial steps in management and may include lifestyle adjustments or changes such as physical activity and diet. Pharmacological options have been used when the non-pharmacological approach has been ineffective. Biofeedback therapy, surgery, sacral nerve stimulation, botulinum toxin injection, and vibrating capsules can be considered in scenarios where the laxatives are ineffective. Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. This paper overviews non-pharmacological therapies for functional constipation.

Systematic review of the utilization of botulinum toxin in Mohs micrographic surgery.

The use of botulinum toxin for off-label indications has become more prevalent, but the specific benefits in Mohs micrographic surgery (MMS) have not yet been fully elucidated. A systematic review was performed of PubMed, Cochrane, EMBASE, and Scopus databases to identify all articles describing the use of botulinum toxin in MMS. Analysis was subdivided into scar minimization, parotid injury, and pain management. A total of nine articles were included. Scar minimization and treatment of parotid injury were the most reported uses. One case reported the use of botulinum toxin for pain management. Off label uses of botulinum toxin are being explored. Additional research is warranted to determine the efficacy and utility of botulinum toxin in MMS.

Beyond Wrinkles: A Comprehensive Review of the Uses of Botulinum Toxin.

BACKGROUND: Botulinum neurotoxin (BoNT) exhibits inhibitory effects on the neuromuscular junction, and its use is well established in cosmetic dermatology. Our review aims to analyze the evidence for its use in the treatment of various dermatological, neurological, gastroenterological, ophthalmological, otorhinolaryngological, dental, urological, gynecological, and cardiovascular disorders. METHODS: A systematic review of the literature was performed for studies published between 2012 and 2022 that discussed the therapeutic use of BoNT in human participants. A total of 58 studies were selected for inclusion in this review.  Results: We discovered a large range of therapeutic applications of BoNT toxin beyond aesthetic and US Food and Drug Administration (FDA)-approved non-aesthetic uses.  Conclusions: BoNT is a powerful neurotoxin that has varied FDA-approved indications and has been studied in a wide range of therapeutic applications. Further investigation through higher power studies is needed to assess the potential of BoNT and expand its versatility across other medical specialties.  J Drugs Dermatol. 2024;23(3):173-186. doi:10.36849/JDD.7243e.

Evaluation of long-term immune response in cattle to botulism using a recombinant E. coli bacterin formulated with Montanide™ ISA 50 and aluminum hydroxide adjuvants.

Botulism is a severe disease caused by potent botulinum neurotoxins (BoNTs) produced by Clostridium botulinum. This disease is associated with high-lethality outbreaks in cattle, which have been linked to the ingestion of preformed BoNT serotypes C and D, emphasizing the need for effective vaccines. The potency of current commercial toxoids (formaldehyde-inactivated BoNTs) is assured through tests in guinea pigs according to government regulatory guidelines, but their short-term immunity raises concerns. Recombinant vaccines containing the receptor-binding domain have demonstrated potential for eliciting robust protective immunity. Previous studies have demonstrated the safety and effectiveness of recombinant E. coli bacterin, eliciting high titers of neutralizing antibodies against C. botulinum and C. perfringens in target animal species. In this study, neutralizing antibody titers in cattle and the long-term immune response against BoNT/C and D were used to assess the efficacy of the oil-based adjuvant compared with that of the aluminum hydroxide adjuvant in cattle. The vaccine formulation containing Montanide™ ISA 50 yielded significantly higher titers of neutralizing antibody against BoNT/C and D (8.64 IU/mL and 9.6 IU/mL, respectively) and induced an immune response that lasted longer than the response induced by aluminum, extending between 30 and 60 days. This approach represents a straightforward, cost-effective strategy for recombinant E. coli bacterin, enhancing both the magnitude and duration of the immune response to botulism.

Effect of refractive errors on the results of botulinum neurotoxin administration in patients with infantile esotropia.

PURPOSE: To investigate the effect of refractive errors on the results of patients followed up with infantile esotropia (IE) and treated with botulinum neurotoxin (BNT) injection. METHODS: The files of patients with IE who presented to the ophthalmology pediatric ophthalmology unit and underwent BNT injection into both medial rectus muscles between 2019 and 2021 were reviewed retrospectively. Sixty eyes of 30 patients were included in the study. Patients with additional systemic or ocular diseases and those with a history of ocular surgery were excluded. Distance and near deviations were measured (with the prism cover test or Krimsky method) before and at the first, third, and sixth months after BNT injection. RESULTS: In Group 1 (n = 20) with a spherical equivalent of + 2.0 diopters (D) or less, the mean near and distance deviation value was both 36.8 ± 12.7 prism diopter (PD) before injection. In Group 2 (n = 10) with a spherical equivalent of above + 2.0 D, the near deviation was measured as 35.0 ± 7.1 PD and distance deviation as 31.8 ± 7.9. At six months after BNT injection, the near and distance deviation values were 20.6 ± 12.3 and 20.6 ± 11.6 PD, respectively in Group 1 and 10.1 ± 10.3 and 8.8 ± 10.8 PD, respectively in Group 2. The change in deviation did not statistically significantly differ between the groups (p > 0.05), but the distance and near deviation values were lower in Group 2 at sixth months after BNT injection. CONCLUSIONS: BNT injection is a preferred method in IE. Higher hypermetropic values seem to increase the success of BNT injection.

Off-label drugs in otolaryngological practice against the background of legal conditions of Polish legislation.

<b><br>Introduction:</b> 'Off-label drug use' refers to the administration of drugs for unapproved indications or age groups, a different dosage or other form of administration. Considering the legal issues, there clearly exists a need to implement rules that would regulate the use of pharmaceuticals outside the scope of a marketing authorisation. The brevity and diversity of Polish laws in the field of health care leads to many interpretative doubts associated with particular legal acts.</br> <b><br>Aim:</b> We aimed to present clinical examples from everyday practice of off-label drug use from the medical and legal perspectives, and to support it with relevant legal acts.</br> <b><br>Material and method:</b> Off-label drug use in various otolaryngology subspecialties - otology (mesna), laryngology (bevacizumab, cidofovir and botulinum toxin) and head and neck surgery (botulinum toxin) - are presented and discussed in detail.</br> <b><br>Results:</b> Fourteen Polish legal acts regarding off-label drug use and 4 from EU legislation are commented on. The algorithm of cascade of decision-making processes in off-label drug use is shown.</br> <b><br>Conclusions:</b> Off-label use of medicinal products is not prohibited in Poland or the EU; nevertheless, it is undeniable that the unclear legal situation regarding the use of medicinal products for nonregistered indications creates difficulties. To minimise a doctor's liability risk, obtaining the informed consent from the patient for such treatment is advisable.</br>.

The Usefulness of Salivary Gland Organoids for Evaluation of the Potency of Botulinum Neurotoxin.

BACKGROUND AND OBJECTIVES: Botulinum neurotoxin (BoNT) is a substance used to treat chronic sialorrhea, muscle dystonia, and is used in cosmetic applications. Measuring the potency of BoNT is crucial because it acts even with a small amount. However, the current methods for measuring the potency of BoNT involve using two-dimensional neuroblastoma cell line-based methods. In this study, we aimed to develop a new method to measure the potency of BoNT using a three-dimensional organoid culture system. MATERIALS AND METHOD: We established the optimal conditions for coculturing N2a neuronal cells with murine salivary gland organoids (SGOs). After determining the appropriate chemical concentrations, we treated the SGOs cocultured with N2a cells with BoNT type A (BoNT/A). We confirmed the expression of salivary gland-related genes and proteins using real-time polymerase chain reaction (PCR) and immunofluorescence staining. RESULTS: The SGOs cocultured with N2a cells showed that the dendrites or axons of neuronal cells were in contact with the outermost layer of the SGOs. When we applied acetylcholine and neostigmine to the coculture systems, the mRNA expression of Aqp5 and Bhlha15, associated with salivary gland secretory cells, increased. However, this effect was reversed when BoNT/A was applied, as confirmed through real-time PCR. CONCLUSION: We found that the coculture system of SGOs and N2a neuronal cells can potentially serve as a potency testing platform for BoNT. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2697-2704, 2024.

The 200-Year Timeline on Botulinum Toxin: From Biologic Poison to Wonder Drug.

The history of botulinum toxin dates back to the late 1700s, when food preparation, storage, and later canning practices led to outbreaks of botulism across Europe and the United States. It is from these initial incidents that the remarkable discovery of botulinum toxin was eventually made, sparking over 200 years of further scientific inquiry and medical innovation. To date, 6 botulinum toxin products have been commercialized in North America with numerous indications across the specialties of ophthalmology, neurology, urology, dermatology, plastic surgery, and otolaryngology. This article traces the key moments and important players in the remarkable journey of this biologic poison and wonder drug. J Drugs Dermatol. 2024;23(1) doi:10.36849/JDD.7288.

Pulsatilla saponin D regulates ras-related C3 botulinum toxin substrate 3 (RAC3) to overcome resistance to paclitaxel in lung adenocarcinoma cells.

BACKGROUND: Paclitaxel, a tubulin-binding agent, is a Food and Drug Administration-approved first-line drug for the treatment of non-small cell lung cancer (NSCLC), for both squamous and non-squamous cell lung carcinoma, with paclitaxel/carboplatin + bevacizumab a common chemotherapy regimen for stage IV non-squamous NSCLC; however, primary or acquired resistance to paclitaxel is gradually increasing, leading to treatment failure. METHODS: Our results show that Ras-related C3 botulinum toxin substrate 3 (RAC3) is overexpressed in cultured paclitaxel-resistant cells and that RAC3 expression levels are negatively correlated with sensitivity of lung adenocarcinoma cells to paclitaxel. Pulsatilla saponin D could inhibit RAC3 expression, and we hypothesize that it may block paclitaxel resistance. Further, we found that treatment with paclitaxel combined with Pulsatilla saponin D, can overcome lung adenocarcinoma cell resistance to paclitaxel alone in cell culture and mouse xenograft models.

[Botulinum Toxin Treatment for Hemifacial Spasm:Based on the Practical Clinical Experience in the Neurology Outpatient Clinic].

Botulinum toxin(BTX)treatment is the first-line neurological treatment for hemifacial spasm(HFS). In my neurology clinic, Clinique Kita Neurologique(CKN), I have provided a cumulative total of approximately 400 BTX treatments for approximately 50 HFS patients for 23 years. Based on my own practical clinical experience, I have demonstrated the efficacy of BTX treatment. In compressive HFS, BTX treatment is indicated in patients who are not indicated or unwilling to undergo neurodecompression surgery. This is also indicated in the case of a long waiting period before surgery. In postparetic HFS, BTX treatment is indicated in patients with spasm and synkinesia. The amount of each BTX injection in postparetic HFS should be less than that in compressive HFS because of latent facial paresis. Although BTX injections can be easily administered in neurology outpatient clinics, it is important to perform the procedure safely and promptly.

Myomodulation Using Botulinum Toxin in Septorhinoplasty for Crooked Noses: Introducing the Concept and Application of Nasal Muscle Imbalance Theory.

The role of septorhinoplasty for adequate correction of deviated nose is well documented, but the rationales and patterns for recurrences after proper rhinoplasty remain unclear. There has also been little attention given to the influence of nasal musculatures on the stability of nasal structures after septorhinoplasty. The aim of this article is to propose our nasal muscle imbalance theory, which may explain the potential reason for redeviation of the noses in the initial period after septorhinoplasty. We postulate that in a chronically deviated nose, the nasal muscles on the convex side will be stretched and develop hypertrophy after prolonged period of increased contractile activity. On the contrary, the nasal muscles on the concave side will undergo atrophy due to reduced load requirement. In the initial period of recovery after a septorhinoplasty to bring the nose back to midline, this muscle imbalance is still uncorrected with unequal pulling forces on the nasal structure because the stronger nasal muscles on the previously convex side is still hypertrophied and exert stronger forces compared with the previously concave side, therefore increasing the risk of redeviation of the nose back to the preoperative side until muscle atrophy occurs in the convex side and a balanced nasal muscle pull is achieved. We believe that postseptorhinoplasty botulinum toxin injections can be used as an adjunct in rhinoplasty surgery to effectively block the pulling actions of the stronger or overacting nasal muscles by speeding up the atrophy process while allowing patient's nose to heal and stabilize in the desired position. However, further studies to objectively confirm this hypothesis is required, which include comparing topographic measurements, imaging and electromyography signals before and after injections in postseptorhinoplasty patients. The authors have already planned a multicenter study to further evaluate this theory.

Botulinum Toxin Treatment for Calf Contouring Based on the Study of Combined Injection of Gastrocnemius and Soleus.

BACKGROUND: Botulinum toxin is administered to paralyze the gastrocnemius muscle and reduce its size, thereby improving the calf contour and reducing the leg circumference of the calf. OBJECTIVES: In pursuit of better efficacy, we designed a new injection protocol that targeted both the gastrocnemius and soleus. An algorithm of botulinum toxin injection for calf contouring was proposed based on the results of the study and ultrasonographic data. METHODS: A prospective, self-controlled, double-blind study was conducted. The gastronemius muscle (GM) group (n = 17) included the patients whose gastrocnemius muscles were treated, and the GM + soleus muscle (SM) group (n = 17) included the patients who had both the gastrocnemius and soleus treated. Parameters including the maximum leg circumference and the subcutaneous fat, gastrocnemius muscle, and soleus muscle thicknesses were collected before and after injection. RESULTS: Both GM and GM + SM injection helped improve calf contour. Although the thickness of the gastrocnemius muscle was reduced, reducing the leg circumference, the subcutaneous fat and soleus muscle had compensatory thickening after injection, especially over the long term, which may affect the efficacy. Compared with the GM group, the GM + SM group effectively reduced the tendency of the soleus muscle to thicken. Calf muscle thickness could be roughly estimated by constructing a fitting equation and measuring height, weight, and leg circumference. CONCLUSIONS: Two injection methods achieved the effect of improving calf contour and reducing the leg circumference with equivalent patient satisfaction. The GM + SM injection group did not show any obvious extra clinical benefit when compared with the GM injection group.

Clostridium botulinum C3bot mediated effects on cytokine-induced psoriasis-like phenotype in full-thickness skin model.

Clostridium botulinum C3 exoenzyme (C3bot) exclusively inhibits RhoA, B and C by ADP-ribosylation and is therefore used as a cell-permeable tool for investigating the cellular role of these Rho-GTPases. Rho-GTPases represent a molecular switch integrating different receptor signalling to downstream cascades including transcriptional cascades that regulate various cellular processes, such as regulation of actin cytoskeleton and cell proliferation. C3bot-induced inhibition of RhoA leads to reorganization of the actin cytoskeleton, morphological changes, and inhibition of cell proliferation as well as modulation of inflammatory response. In this study, we characterized the C3bot-mediated effects on a full-thickness skin model exhibiting a psoriasis-like phenotype through the addition of cytokines. Indeed, after the addition of cytokines, a decrease in epidermal thickness, parakeratosis, and induction of IL-6 was detected. In the next step, it was studied whether C3bot caused a reduction in the cytokine-induced psoriasis-like phenotypes. Basal addition of C3bot after cytokine induction of the full-thickness skin models caused less epidermal thinning and reduced IL-6 abundance. Simultaneous basal incubation with cytokines and C3bot, IL-6 abundance was inhibited, but epidermal thickness was only moderately affected. When C3bot was added apically to the skin model, IL-6 abundance was reduced, but no further effects on the psoriasis-like phenotype of the epidermis were observed. In summary, C3bot inhibits the cytokine-induced expression of IL-6 and thus may have an impact on the pro-inflammatory immune response in the psoriasis-like phenotype.

Anatomical Considerations for the Injection of Botulinum Neurotoxin in Shoulder and Arm Contouring.

The utilization of botulinum neurotoxin in the field of body contouring is on the rise. Body contouring procedures typically focus on specific muscle groups such as the superior trapezius, deltoid, and lateral head of the triceps brachii. The authors propose identifying optimal injection sites for botulinum neurotoxin to achieve desired aesthetic contouring of the shoulders and arms. The authors conducted a modified Sihler's staining method on specimens of the superior trapezius, deltoid, and lateral head of the triceps brachii muscles, totaling 16, 14, and 16 specimens, respectively. The neural distribution exhibited the most extensive branching patterns within the horizontal section (between 1/5 and 2/5) and the vertical section (between 2/4 and 4/4) of the superior trapezius muscle. In the deltoid muscle, the areas between the anterior and posterior deltoid bellies, specifically within the range of the horizontal 1/3 to 2/3 lines, showed significant intramuscular arborization. Furthermore, the middle deltoid muscle displayed arborization patterns between 2/3 and the axillary line. Regarding the triceps brachii muscle, the lateral heads demonstrated arborization between 4/10 and 7/10. The authors recommend targeting these regions, where maximum arborization occurs, as the optimal and safest points for injecting botulinum toxin.

Infectious Granuloma With Mycobacterium abscessus After Facial Injection of Botulinum Toxin: A Case Report.

Botulinum toxin injections have garnered increasing employment in facial rhytidectomy due to their demonstrable efficacy and safety profile. In this study, the authors present the case of a 39-year-old woman who manifested painful crimson nodules and multiple abscesses on her face, which manifested 1 week postinjection. Subsequent histopathological scrutiny unveiled the development of histiocytic granulomas accompanied by infiltrates of inflammatory cells, and microbiological investigation and polymerase chain reaction assays identified the causative agent as Mycobacterium abscessus .

Treatment of Chin Retrusion With Botulinum Toxin Plus Hyaluronic Acid Filler in Comparison With Hyaluronic Acid Filler Alone: A Randomized, Evaluator-Blinded, Controlled Study.

BACKGROUND: Hyaluronic acid (HA) has already been widely administered for chin augmentation. Patients with chin retrusion frequently present with increased chin hypertonia. Monotherapy with HA falls short in addressing the multifaceted cosmetic concerns associated with chin retrusion. OBJECTIVES: This study aimed to investigate the clinical efficacy and safety of the combination therapy involving botulinum toxin (BTX) and HA in the treatment of chin retrusion. METHODS: We enrolled patients with moderate to severe chin retrusion for 9 months of follow-up after they received either combined treatment with BTX plus HA or monotreatment with HA. We also calculated the surface-volume coefficient with 3-dimensional digital scanning technique, and evaluated outcomes based on the Allergan Chin Retrusion Scale (ACRS), the Global Aesthetic Improvement Scale (GAIS), and treatment-related adverse events (TRAEs). RESULTS: A total of 50 patients were recruited and randomized to the treatment group (BTX plus HA) or control group (HA alone) in a 1:1 ratio. Patients in the treatment group exhibited significantly higher surface-volume coefficients during the first 6 months (P < .05). ACRS scores and responder rates in the 2 groups remained similar throughout the follow-up (P > .05). Within the initial 3 months, the GAIS responder rate in the treatment group was significantly higher than that in the control group (P < .05). Mild TRAEs were observed in both groups, and subsided within 7 days. There was no increase in adverse effects with the combined treatment. CONCLUSIONS: In comparison to monotherapy, the combined treatment not only improved the surface-volume coefficient of hyaluronic acid but also achieved similar ACRS scores with less HA volume. Furthermore, the combination treatment yielded superior treatment outcomes for individuals with chin retrusion.

Gastric peroral endoscopic myotomy versus botulinum toxin injection for the treatment of refractory gastroparesis: results of a double-blind randomized controlled study.

INTRODUCTION: Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI). METHODS: This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life. RESULTS: 40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant). CONCLUSION: G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.

Effectiveness and safety of botulinum neurotoxin for treating dyssynergic defecation: A systematic review and meta-analysis.

Dyssynergic defecation (DD) is a common cause of chronic constipation. Owing to the lack of a comprehensive synthesis of available data on the effectiveness of botulinum neurotoxin (BoNT) for treating DD, we performed a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane databases from inception to May 9, 2023. The outcomes comprise short-term and long-term symptom improvement, various anorectal function measurements, complications of fecal incontinence, and symptom improvement after repeated BoNT injections. A meta-analysis comparing BoNT injection with either surgery or biofeedback (BFB) therapy in treating DD was also conducted. Subgroup analysis and meta-regression were performed to identify possible moderator effects. We included five randomized controlled trials, seven prospective studies, and two retrospective observational studies. Short-term potential improvement in symptoms (event rate [ER], 66.4%; 95% CI, 0.513 to 0.783) was identified, but in the long-term (>12 months), this effect was decreased (ER, 38.2%; 95% CI, 0.267 to 0.511). Short-term improvements in objective anorectal physiologic parameters were also observed. Repeated BoNT injection was effective for patients with symptom recurrence. Subgroup analysis revealed enhanced long-term symptom improvement with high-dose BoNT, but this treatment also increased the risk of complications and recurrence compared with low doses. The effectiveness, complications, and recurrence of symptoms associated with BoNT injection and surgery did not differ significantly. BoNT injection significantly provided short-term symptom improvement but also heightened the risk of incontinence compared with BFB therapy. Our systematic review and meta-analysis indicated that BoNT could be beneficial for short-term symptom improvement in patients with DD, but this effect tended to decline 12 months after injection. Standardized BoNT intervention protocols remain warranted. Among the several treatments for DD, we concluded that BoNT injection is not inferior to other options considering its effectiveness in relieving symptoms, the associated complication development, and the risk of symptom recurrence.

12†The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study - Final Report.

Studies from the UK have reported declining rates of surgery for childhood esotropia. It is not known if this equates to a reduced incidence of essential infantile esotropia (EIE). A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence presenting features and management of EIE in the UKData from a prospective national observational cohort of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period was collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥ 20 prism dioptres (PD), presenting at ≤ 12months, with no neurological or ocular abnormalities were identified through BOSU. Follow up data was collected at 12 months. Data was collected on the age, gender, ethnicity, birth history, age at diagnosis, age at intervention, angle of esotropia, refraction, associated features of amblyopia, overelevation in adduction (OEIA), latent nystagmus and dissociated vertical deviation (DVD), method of management and outcomes.During the period of observation between October 2017 to October 2018 a total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births with a corrected incidence of 1 in 9027 live births allowing for estimated under reporting. The mean age of diagnosis and intervention were 7.05± 2.6 months (range 2 to 12 months) and 14.7± 4.9 (range 6.5-28.1 months) respectively. The majority were Caucasians 86.5% and 52.7% were female. Management was surgical in 59.6%, and botulinum toxin alone in 22.8%, 17.5% were observed. There was no significant difference in the age of presentation (P=0.6), gender (P=0.8), prematurity (P=0.5), deprivation indices (P=0.68), refraction (P=0.7), OEIA (P=0.6), DVD (P=0.7) or follow up (P=0.3) between the three groups. The preoperative angle of esotropia was smaller in the observation group (P=0.04). The post-operative angle of esotropia was not statistically significant between botulinum toxin or surgery (P=0.3) though the age of intervention was earlier in the botulinum group (P=0.007). Early intervention did not influence the motor post intervention outcomes between 0-10 prism dioptres of esotropia (P=0.78). Amblyopia (P=0.02) and latent nystagmus (P=0.009) was more common in the observation group.The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention did not influence motor outcomes. Parental choice and amblyopia treatment were reasons cited for conservative management in the observational group.