Long-Term Effects of Botulinum Toxin A for Horizontal Concomitant Strabismus in Chinese Children.

INTRODUCTION: For childhood strabismus, early surgical intervention improves both motor and sensory outcomes. Botulinum toxin type A (BTX-A) injection is an alternative to incisional surgery that is fast, less invasive, and preserves a more normal biomechanical construct. This study was undertaken to assess the safety and effectiveness of BTX-A for horizontal concomitant strabismus in children in our institution. PATIENTS AND METHODS: Records of all children less than age 18 years with follow-up at least 12 months who were treated with BTX-A for horizontal concomitant strabismus at Beijing Children's Hospital between December 2014 and February 2021 were reviewed retrospectively. Bilateral injections of BTX-A (Henli, 1.25 IU to 5 IU/0.1 ml) were made into the medial or lateral rectus muscles according to the angle of deviation. Reinjection was permitted if the initial alignment was not satisfactory within 1 to 6 months post-injection. Motor success was defined as a final misalignment ≤10 PD. Sensory success was defined as the presence of any evidence of sensory fusion, distance stereopsis, or near stereopsis at the last visit. RESULTS: Seventy-one patients were included. Fifty-two had esotropia, and 19 had exotropia. There was a significant decrease in the angle of deviation in all treated patients. The overall motor success rate was 60.6%. The motor success rate was highest in children with esotropia <50 PD (81.5%). Motor success was better for children with partially accommodative esotropia and acquired non-accommodative esotropia (80%, 83.3%, respectively) than for children with infantile esotropia (47.4%). Compared with the esotropia group, the fusion was significantly higher in the exotropia group (p = .007), and the proportion of patients with stereoacuity of better than 100 sec arc was higher also in the exotropia group (71.4%, p = .007), evidence of sensory outcomes were significantly better in the exotropia group. Complications were few. Twenty patients (28.2%) developed transient ptosis after injections; transient vertical deviations were seen in 3 patients (4.2%); and subconjunctival hemorrhage was seen in 5 patients (7%). CONCLUSIONS: BTX-A appears to be an effective treatment for the management of horizontal strabismus with motor outcomes best in children with acquired smaller-angle esodeviations. Children with exodeviations had better sensory outcomes in this cohort. A randomized controlled study comparing incisional surgery to BTX-A will be important for guiding future treatment decisions.

Use of Botulinum Toxin A in the Treatment of Intermittent Exotropia: Factors Affecting Treatment Outcome.

PURPOSE: To evaluate the efficiency of botulinum toxin A (BTA) injection in the treatment of intermittent exotropia (IXT) and determine factors affecting treatment outcome. MATERIALS AND METHODS: A total of 74 patients diagnosed with any type of IXT were included in the study. BTA injection was administered into both lateral rectus muscles. Gender, refractive error, age, pre- and post-injection measurements of ocular deviation, age at the time of the first BTA injection, number of injections, duration of misalignment, age at the onset of misalignment, presence of amblyopia, presence of anisometropia, preterm birth history, type of delivery, presence of any neurological disorder, follow-up period, postoperative ptosis, and vertical deviation were recorded. The final angle of deviation was used in the statistical analysis. Successful motor alignment was defined as a deviation of ≤10 prism diopters (PD) at distance. The relationship of all factors with treatment success was analyzed using the binary logistic regression analysis. RESULTS: A total of 74 patients, 40 female and 34 male, were included in the study. All the patients were followed up for six to 53 months after the first BTA injection, and the mean follow-up was 16.1 ± 11.1 months. Before the first BTA injection of the patients, the mean amount of deviation was measured as 25.7 ± 14.2 (range, 0-60) PD at near and 37.1 ± 10.9 (range, 16-65) PD at distance. According to the most recent examination of the patients, the mean amount of deviation was 10.6 ± 9.8 (range, 0-45) PD at near and 16.4 ± 10.2 (range, 0-45) PD at distance. There was a statistically significant difference between the first and last examinations of the patients in relation to the amount of deviations measured at both near and distance (p < .001). Successful motor alignment (orthotropia within 10 PD for exodeviation) was achieved in 42 patients (56.7%). Thesuccess of treatment increased with the decreased amount of deviation at distance before the BTA injection. CONCLUSIONS: In patients with IXT, BTA injection into the lateral rectus muscles is an effective procedure, which is also less invasive and taking shorter time than surgery, and it can be considered as an alternative treatment option in those with small-medium angle IXT.

Comparison of Botulinum toxin type A with surgery for the treatment of intermittent exotropia in children.

BACKGROUND: The aim of this study was to observe the effectiveness of botulinum toxin type A (BTA) in the treatment of intermittent exotropia (IXT) in children compared with strabismus surgery. METHODS: One hundred forty-four children with a clear diagnosis of IXT and an indication for surgery were eligible for inclusion. Subjects were divided into two groups based on parental decision: the BTA injection group (injection group) or the conventional surgery group (surgery group). All cases were followed up for 6 months. The primary outcome was a comparison of the success rate (deviation between - 10 and + 10 PD) between the two groups at 6 months after the initial treatment. Secondary outcomes included change in deviation, visual function, and post-surgical complications. RESULTS: Seventy-two patients were enrolled in each group. At 6-month follow-up, there was no significant difference in the success rate between the injection and surgery groups (52.8% vs 66.7%, P = 0.13; postoperative deviation - 12.22 ± 10.80 PD vs - 9.17 ± 10.30 PD, P = 0.09). The binocular Visual function, except for near stereoacuity, improved after treatment in both groups, while the fusion recovery rate was higher in the surgical group (68.1% vs 95.8%, P < 0.001). Transient complications in the injection group included diplopia, ptosis, and subconjunctival hemorrhage, whereas subconjunctival hemorrhage, conjunctival edema, foreign body sensation, pain, and diplopia were seen in the surgical group. The complications of BTA were relatively mild. CONCLUSIONS: BTA is as effective as surgery in the treatment of IXT in children, but the recovery of the fusion is lower than surgery. TRIAL REGISTRATION: The study has completed the clinical registration on ( ChiCTR-INR-17013777 ).

Bupivacaine Injection without Electromyographic Guide for Correction of Residual Esotropia and Exotropia after Strabismus Surgery.

Purpose: To evaluate the effect of bupivacaine injection without electromyographic guide for correcting residual esotropia and exotropia after strabismus surgery. Methods: Thirty patients with residual esotropia or exotropia after strabismus surgery were included in the study. Three milliliters of bupivacaine 0.5% were injected into medial or lateral rectus muscle without electromyographic guide. Results: The mean pre-injection misalignments were 14.8 ± 3.4 (8-20) PD at distance and 14.7 ± 4.4 (6-25) PD at near. The 1 month post-injection alignment changes were 5.2 ± 2.6 (2-13) PD at distance and 6.5 ± 3.1 (2-18) PD at near. The 6 months post-injection alignment changes were 5.8 ± 2.6 (2-13) PD at distance and 7.0 ± 3.6 (2-18) PD at near. LogMAR of the worst eye had strong correlations with 6 months far alignment change (ρ = 0.39, p = .04), 6 months near alignment change (ρ = 0.41, p = .03), and 12 months near alignment change (ρ = 0.69, p = .01). Conclusion: The effect of bupivacaine injection without electromyographic guide for correcting residual esotropia or exotropia after strabismus surgery was between 2 and 18 PD, comparable with other studies on unoperated cases. The effect of bupivacaine may increase with decreasing visual acuity.

Efficacy of Botulinum Toxin Injection in Exotropia Treatment.

PURPOSE: Botulinum toxin (Botox) therapy is a well-known option for strabismus management and is often used in managing esotropia. Exotropia is also a common type of strabismus; however, the effectiveness of Botox in improving exotropia is still ambiguous. In this study, we report our experience in using Botox to manage the various types of exotropia. METHODS: A retrospective cohort study was conducted at King Khaled Eye Specialist Hospital Riyadh, Saudi Arabia. Medical records of patients with exotropia who received Botox from 2014 to March 2020 were reviewed. The main success indicator was a remaining angle of less than 10 prism diopters (PD). RESULTS: A total of 97 cases were reviewed, with 57 (58.8%) males and 40 (41.2%) females. The age ranged from 2 months to 40 years. The most prevalent diagnosis was sensory exotropia. Overall, 28 patients (28.9 %) and 49 patients (50.5%) achieved an angle of deviation within 10 PD and within 20 PD, respectively. Female patients had a better response to Botox than males, with 32.5% of them achieving an angle of deviation within 10 PD and 60% achieving an angle of deviation within 20 PD. We found that the change in the angle of deviation increased as the Botox dose was increased. CONCLUSION: Botox represents a possible safe alternative to surgery in the management of some exotropia types. The success rate differs by type, with basic exotropia scoring the highest. The presence of poor vision and amblyopia leads to a significantly lower success rate.

Treatment of Intermittent Exotropia of the Convergence Insufficiency Type with Bupivacaine 0.75%: 5-Year Experience and Outcomes.

INTRODUCTION: Bupivicaine has been shown to stimulate ocular muscle structure and length after injection into ocular muscles. Bupivicaine 0.75% has been utilized in the treatment of strabismus to alter ocular alignment by strengthening an ocular muscle. This study is designed to report 5-year follow-up outcomes after bupivicaine injection. METHODS: A retrospective chart review of all bupivicaine treated strabismus patients with symptomatic intermittent exotropia of the convergence insufficiency type (CIXT) from 2009 through 2016. Success was measured as resolution of symptoms (diplopia, difficulty reading, intermittent blurry vision, and headaches) with or without prisms (<5Δ). RESULTS: At a 5-year outcome, success rate was 80%. Mean near deviation changed from 10.6Δ to 3.8Δ. Outcome was the same at 6 months (n = 124) vs 5 years (n = 30) unless a new onset strabismus occurred (TAED, CN palsy, CVA). In older patients, a large number (10%) of patients developed new onset strabismus. There were no moderate or severe complications after injection. There appears to be a predictable dose response curve. DISCUSSION: At 6 months outcome, treatment of CIXT with bupivacaine (91%) has a similar rate of success as traditional resection (92%). Older patients need to be informed of the incidence of new onset strabismus causing recurrence of symptoms (10%). CONCLUSION: At 5 years outcome, bupivicaine 0.75% offers a simple alternative therapy for CIXT type strabismus patients. There is little risk and less expense than traditional resection surgery without the overcorrections.

Acute transient large-angle exotropia caused by traumatic orbital contusion.

We report an unusual case of acute large-angle left exotropia associated with blunt orbital trauma in a healthy 8-year-old boy. Examination revealed a large-angle left exotropia with limitation in adduction of the left eye. Microhyphema and commotio retinae of the left eye were also present. High-resolution orbital magnetic resonance imaging (MRI) demonstrated perimuscular and intramuscular edema mostly involving the left medial rectus muscle but also involving the left lateral rectus muscle. The extraocular muscle insertions were intact. Complete resolution of the strabismus and adduction limitation occurred within 24 hours of starting systemic steroid therapy. This case highlights the utility of high-resolution imaging to assess for injury to the extraocular muscles. If disinsertion, transection, or rupture of the muscle is not present on imaging, resolution may occur with systemic steroid therapy and surgical intervention is not needed.

[Third cranial nerve palsy and Purtscher retinopathy in a child with multiple injuries]. / Parálisis del tercer nervio craneal y retinopatía de Purtscher en niña politraumatizada.

CASE REPORT: A 4 year-old girl was referred to our hospital after have suffered a severe accident. The patient was diagnosed with complete third nerve palsy in her right eye and Purtscher retinopathy in her left eye. DISCUSSION: Purtscher retinopathy is a rare condition. The diagnosis is made on clinical ground and its treatment is not well defined although it is believed that systemic steroids could improve the visual outcome. Traumatic third nerve palsy has a poor spontaneous recovery. The use of botulinum toxin might be useful in children to improve the recovery rate, maintaining binocularity, and avoiding amblyopia in other cases.

Efficacy of botulinum toxin in the treatment of intermittent exotropia.

BACKGROUND: Multiple surgical interventions are burden to patients with intermittent exotropia (IXT) due to a high recurrence rate. This study was designed to evaluate the efficacy of botulinum toxin injection in the treatment of intermittent exotropia (IXT). METHOD: A total of 21 patients with IXT, who had a far deviation of less than 40 prism diopters (PD), were enrolled. All cases were followed for at least 6 months with non-surgical management and had decremented fusional control (increasing 3 or more scores in Newcastle Control Score [NCS]). Botulinum toxin was injected (10 units Dysport) to both lateral rectus muscles. Fusional control, sensory and motor status were evaluated at 1 day, 1 week, and 1, 3, and 6 months after injection to compare with the pre-injection values. RESULTS: Fusional control (based on NCS) showed a significant improvement during 6-month follow-up. Mean NCS was 4.4±0.8 SD before botulinum toxin injection and 1.4±0.4 SD after 6 months (p<0.001). Evaluation of sensorial status with Worth Four Dot Test (WFDT) also demonstrated an improvement of fusion (the percentage of patients demonstrating fusion on WFDT were 10.5% before injection and 61.5% after 6 months). The mean far and near deviations decreased during 6 months of follow-up examination. Satisfactory outcome (stable binocular alignment of the eyes to an orthophoria+/-10 PD in primary position) for far distance was achieved in 38.1% at 6 months. The percentage of satisfactory outcome at near was 86% at 6 months follow-up examination. CONCLUSION: Botulinum toxin injection to lateral rectus muscles seems to be a promising procedure in the management of fusional control, far and near deviations in patients with intermittent exotropia in short time.

"My eyes are turned outside".

A 78-year-old white woman noted progressively worsening headache, fluctuating decreased vision, dizziness, and binocular horizontal and vertical diplopia of two months duration. She had a 40 prism diopter exotropia and bilateral ophthalmoplegia. An initial temporal artery biopsy (TAB) was negative for findings of giant cell arteritis (GCA). Empiric prednisone was continued, and a second TAB was positive for GCA. In time there was complete resolution of the ophthalmoplegia.

[Intermittent exotropia: bilateral lateral rectus recession treatment and long term results]. / Exotropías intermitentes: tratamiento mediante retroinserción bilateral de rectos laterales y resultado a largo plazo.

PURPOSE: To describe the long-term surgical outcomes of bilateral lateral rectus recession in patients with intermittent exotropia. METHODS: Retrospective review of 18 patients diagnosed with intermittent exotropia between 1995 and 2005 who underwent surgical treatment in the Ramon y Cajal Hospital. RESULTS: Of the 18 patients with intermittent exotropia, 50% were basic subtype. All of them underwent bilateral lateral rectus recession, associated with a previous failed botulinum toxin injection in 8 of them. Satisfactory results (less than 10 PD orthophoria) were obtained in 68.2% of the patients after a 4.5-year follow-up period. CONCLUSIONS: Bilateral lateral rectus recession is an effective and stable surgical procedure in the long-term motor control of intermittent exotropia, especially in basic subtype. Previous injection of botulinum toxin did not affect the results.

Action of botulinum toxin on isometric contraction of medial and lateral rectus muscles in esotropic or exotropic patients.

PURPOSE: To study the action of botulinum toxin A on isometric contraction of the medial and lateral rectus muscles in esotropic or exotropic patients. METHODS: Isometric contraction in patients with strabismus (exotropic and esotropic) and in volunteers without strabismus was compared 30 days after the use of botulinum toxin A. RESULTS: Findings show that this drug has changed the strength ratio between direct agonist and antagonist muscles. This has promoted the displacement of the point of equilibrium between muscle strengths toward the nasal direction in esotropic cases, toward the temporal direction in exotropic cases, and subsequent deviation of the eye toward its primary position. The average achieved correction was approximately 10 prism diopters in both groups of patients. CONCLUSION: In both exotropia and esotropia, the average variations in the induced points of equilibrium related to injection of botulinum toxin A were similar. This means that the greatest percentage of corrections happened in cases of small deviations.

Bupivacaine injection to treat exotropia and esotropia.

PURPOSE: To report the results of bupivacaine injection into the extraocular muscles to treat horizontal strabismus, both exotropia and esotropia. METHODS: Bupivacaine, 4.5 ml of a 0.50% solution, was injected into the medial rectus muscle in each of 14 exotropic patients and into the lateral rectus muscle in each of 6 esotropic patients with electromyographic control. The measures of alignment were made before the procedure and 1, 3, 6, and 12 months after injection. RESULTS: Of 20 patients, 15 had improved ocular alignment with the average change of 8.46, 8.2, 8.33 and 9 prism diopters (PD) at 1,3, 6 and 12 months, respectively. Two of 5 (40%) incomitant strabismus patients and 13 of 15 (86.66%) comitant strabismus patients had improvement in ocular alignment. Eleven of 14 exotropic patient and 4 of 6 esotropic patients had improvement in ocular alignment, averaging 9.73, 9.36, 9.54 and 6 PD in the exotropic group and 5, 5, 5, and 10.5 PD in the esotropic group. There was no serious complication from the injections. CONCLUSIONS: Bupivacaine injection improved ocular alignment in some patients. Denervated extraocular muscle did not respond well to bupivacaine. Bupivacaine improved ocular alignment equally in esotropic and exotropic patients.

The role of botulinum toxin in decompensated strabismus.

BACKGROUND: The surgical management of decompensated strabismus is well described. Conservative treatment may employ the use of lenses and prisms. However, the use of botulinum toxin in decompensated squint is poorly documented. In these patients, with the potential for fusion, botulinum toxin may serve to stabilize the ocular alignment by bringing the images within the fusion range. PURPOSE: The aim of this study was to assess the role of botulinum toxin in the treatment of decompensated squints. METHODS: A retrospective case series involving 92 patients with decompensated squints between December 1990 and July 2005. Botulinum toxin was injected into the lateral rectus in 45 cases and into the medial rectus in 47. This was performed under local anesthesia in 74 cases, the remainder with ketamine anesthesia. Patients were assessed preoperatively at 2 weeks, 4 months, and a minimum of 12 months postoperatively. We defined successful treatment where the resultant stabilized deviation was less than or equal to 10 prism diopters with resolution of diplopia. RESULTS: In this study, 47 patients had a decompensated microesotropia and 45 had a decompensated exophoria. We found that 27 (29.3%) patients were asymptomatic following injection of botulinum toxin. Fourteen (15.2%) patients were better controlled and did not require further intervention. Subsequent surgery was performed in 45 patients (48.9%). CONCLUSION: Our results suggest almost half of those patients requiring treatment for decompensated squint benefit from botulinum toxin, without requiring surgical intervention. This approach is less invasive and allows potential for recovery of binocular function.

Long-term management of strabismus with multiple repeated injections of botulinum toxin.

BACKGROUND: In the healthcare system in the United Kingdom, a number of patients may be offered botulinum toxin as an alternative to surgery in the treatment of their strabismus. We report on our experience of treating those who have received 25 or more injections. METHODS: A retrospective review of the botulinum toxin clinic database was used to identify patients who underwent 25 or more injections between November 1982 and January 2006. All patients with strabismus who met this criterion were included. A statistical analysis was performed in which we compared aspects of this group with those who had received 24 or fewer injections. RESULTS: Fifty-seven patients (0.90%) fulfilled our criteria. There were 37 women and 20 men, with a mean age at first injection of 39 years (range, 15 to 80 years). The number of injections per patient ranged from 25 to 68 (mean, 34). The duration of treatment was between 3 and 22 years. The time interval between injections tended to increase in most patients and the angle tended to reduce. There was no statistical difference between the age at first injection, sex, site injected, diagnosis, and complication rate between the long-term group and the group that received 24 or fewer injections. The long-term group, however, had undergone more previous operations (p < or = 0.001) and had a lower degree of binocularity (p