Treatment of the comitant adquired esotropia residual deviation

PurposeTo review the therapeutic options in the management of residual esotropia, particularly focusing on the effectiveness of botulinum toxin.MethodsRetrospective study of cases of post-surgical residual esotropia treated in our hospital from January 1999 to January 2008. Visual acuity and motor outcomes were analysed in the patients who received botulinum toxin injection.ResultsOf the 200 cases reviewed, 91% of the patients had a new surgery, 5% of patients refused any treatment, while 8 patients (4%) received botulinum toxin injection. Visual acuity (Snellen) before surgery, before toxin and after toxin injection in the right eye was 0.77 (SD 0.2), 0.86 (SD 0.2) and 0.97 (SD 0.2), respectively, and in the left eye: 0.76 (SD 0.1), 0.91 (SD 0.09) and 0.97 (SD 0.2), respectively. The percentage net change in the angle of deviation at far and near distance after toxin injection in the last follow-up was 41.66% and 10%, respectively.The mean follow-up after botulinum toxin injenction was 30.8 months.The success rate (ocular alignment in primary eye position) after toxin at the end of follow-up was 75%.ConclusionsResidual esotropia may be managed with further surgery or with botulinum toxin injection. The first option is more common, but in selected cases botulinum toxin injection may provide very successful outcomes with a low incidence of complications.     

Empleo de toxina botulínica en paciente con nistagmus congénito de tipo pendular

Case reportWe report the case of a 5 month-old male diagnosed with congenital nystagmus and oculocutaneous albinism. The initial examination showed pendular horizontal nystagmus with high amplitude and without blocking position or foveal fixation periods. A 2.5 IU injection of botulinum toxin was administered in the horizontal rectus muscles of both eyes in two sessions separated by 6 weeks. This led to a decrease in amplitude of nystagmus and early development of binocular visual acuity of 4.8 cycles/cm.ConclusionFaced with diagnosis of horizontal nystagmus in the early stages of development, and in order to avoid periods of foveal fixation, the use of botulinum toxin leads to a temporary reduction in its amplitude and an improvement in visual acuity with low complication rates. Given the possibility of spontaneous improvement described in these patients, studies are needed with longer follow-up to establish the advantage of long term treatment.     

Horizontal sensory strabismus: characteristics and treatment results

PurposeTo study the types of horizontal sensory strabismus, their causes, and treatment outcomes.MethodsA retrospective analysis of 44 patients with horizontal sensory strabismus who were treated from 2002 to 2007. Patients whose worse eye vision was inferior or equal to 0.2 were included. The deviation angle in primary position, causes, type of treatment, and pre-operative or post-operative diplopia were studied. A good result was considered if the final deviation was less than 10 prism diopters (pd).ResultsOf the patients studied, 63.6% had exotropia and the 36.4% had esotropia. The visual acuity was between 0.1 and no light perception in 75% of patients. The causes responsible for low vision were congenital in 28, and acquired in 16 cases. The mean deviation was 46.7 pd. Diplopia was present in 5 cases, which were resolved with surgical treatment in 3 of them. The eye with reduced vision was operated on in 37 patients, both eyes in 6 cases, and botulinum toxin was injected in 1 case. The final outcome was successful in 90.6% of the cases which were surgically treated. The mean follow up was 31.84 months.ConclusionsThere were twice as many exotropias as esotropias. Strabismus surgery of the amblyopic eye shows excellent results without the need of new operations. There were no new diplopia cases.     

Botulinum toxin A in the treatment of congenital nystagmus in children

PURPOSE: To evaluate the use of, botulinum toxin A in the treatment of congenital nystagmus in children. MATERIAL AND METHODS: 32 children with nystagmus and esotropia (group I), nystagmus and exotropia (group II) and horizontal and vertical nystagmus (group III). Intramuscular injections of botulinum toxin A was performed in all treated children. RESULTS: In group I the amplitude of nystagmus diminished of 50%, in group II of 42.9% and in group III of 28,6%. Near and distant visual acuity improved in all treated children. CONCLUSIONS: Treatment of congenital nystagmus with botulinum toxin A causes reduction of the amplitude of nystagmus, partial improvement of visual acuity and improvement of anomalous head posture.     

The Role of Botulinum Toxin in the Treatment of Strabismus

ABSTRACT

Purpose: To perform a systematic review of the application of botulinum toxin A (BTA) in the management of strabismus in the adult and pediatric populations.

Materials and methods: A systematic literature search was performed using the Medline database.

Results: In 1989, with the FDA approval of botulinum toxin (onabotulinum toxin A, or BTA) for the treatment of strabismus, patients were provided with an alternative to surgical recession. In this review, we discuss the uses of BTA in the treatment of acute onset comitant esotropia or smaller angle esotropia and as an adjunct to surgery for larger angle esotropia or sixth nerve palsy. Its uses are also explored in intermittent exotropia and vertical strabismus, including thyroid-associated orbitopathy, fourth nerve palsies, and other orbital pathology.

Discussion: Despite its transient kinetics, BTA can have permanent effects on ocular alignment, promoting binocularity and reduction of diplopia, and can serve as a primary treatment or a muscle sparing option in patients at risk of anterior segment ischemia or need for future surgeries.     

Clear lens extraction for the treatment of persistent accommodative spasm after head trauma

We report the case of a 28-year-old man with decreased visual acuity after closed head trauma sustained in a motor vehicle accident 16 weeks earlier. Several structures thought to be associated with the control of accommodation were injured. The patient had a persistent accommodative spasm causing up to 7.0 diopters of pseudomyopia. We present the patient's progress through the clinic, including manifest and cycloplegic refractions and results of a trial with atropine drops, and successful transition to bilateral pseudophakia 2 years and 9 months after the accident.     

Orbital Cellulitis after Faden Operation on the Medial Rectus

Background Orbital cellulitis after strabismus surgery is uncommon, may cause blindness and may lead to death. Very few cases have been described in detail due to the low incidence of this complication. Methods We report the first case of orbital cellulitis following Faden operation on the medial rectus muscle. We believe that the infection was due to asymptomatic ethmoid sinusitis. Our case is compared with other cases previously reported. Results A two-year-old boy was surgically treated for residual esotropia after two botulinum toxin A injections. Two days after surgery, signs of orbital cellulitis developed in his right orbit. CT-scan disclosed right ethmoid sinusitis that spread to the orbit after surgery. After intravenous antibiotic treatment, the infection resolved with full restoration of visual acuity and ocular motility. Conclusion Despite adequate measures to prevent infection, orbital cellulitis may complicate strabismus surgery. Patients must be instructed to recognize early symptoms of this severe infection and call the surgeon immediately. Diagnosis may be confirmed by CT-scanning of the orbits. Prompt treatment with intravenous antibiotics usually leads to full recovery.     

Botulinum injection for the treatment of acute esotropia resulting from complete acute abducens nerve palsy

PurposeThe objective of this study was to investigate the effectiveness of botulinum toxin A (BTX-A) injections in the treatment of acute esotropia resulting from complete acute abducens nerve palsy.MethodsFifteen patients treated for complete acute abducens nerve palsy in our clinic were retrospectively reviewed. All patients who experienced an onset within 3 months and who were treated with early subtenon BTX-A injections at the ipsilateral medial rectus muscle without electromyography (EMG) guidance were included in this study. Responses and complications were recorded during a follow-up of at least 6 months.ResultsThirteen patients who had trauma and two patients who had brain tumor that caused their abducens nerve palsy were enrolled. Overall, six patients (40%) had full recovery and two patients (13%) had partial recovery, but the residual esotropia could be tolerated with prism correction in an average of 14.6 weeks. Seven patients (47%) received strabismus surgery afterward. Patients who did not respond well to early BTX-A injections at the 1-week interval were prone to subsequent surgical intervention (p = 0.026). Three eyes (20%) had transient subconjunctival hemorrhage following the subtenon space injection; no other complications were found after the treatment.ConclusionBTX-A offers patients with complete abducens palsy a possible better chance to regain binocular vision and indicates whether additional surgical interventions are needed for these patients. We also discovered that the subtenon space injection of BTX-A without EMG guidance was a safe, time-saving, and simple technique.     

Efficacy of Botulinum Toxin in the Treatment of Convergence Spasm

Background: Previous studies have shown that botulinum toxin can be an important adjunct to management of convergence spasm. However, we have not experienced the same level of success in our cohort of patients. Methods:Using retrospective review, we collected data on patients presenting to our department with convergence spasm. This included presenting symptoms, examination findings, response to atropine and plus lenses, number and dosage of botulinum toxin injections received, and the status at last follow-up/discharge. Results: We identified a total of 6 patients with a male: female ratio of 1:1 and mean age of 44.3 years. Commonest symptom was diplopia followed by headache and blurred vision. Depression was present in 4 out of 6 patients.

Average pre-injection deviation for near was 32.5 PD ET (Prism Diopters esotropia) and for distance was 27.7 PD ET. All of the patients received botulinum toxin injections to the medial rectus muscle. The response to toxin was variable with an average near deviation at 2 weeks of 10 PD XT (exotropia), range 20 PD XT to 25 PD ET and at 3 months 12.5 PD ET (10 PD XT to 35 PD ET). At the last follow-up, after the toxin effect had worn off, all the patients returned to the pre-injection levels and the symptoms recurred. Conclusion: The response of patients with convergence spasm to botulinum toxin was variable with a recurrence of the deviation once the effect wore off. In our experience, botulinum toxin has a limited role in the management of convergence spasm.     

Transconjunctival botulinum toxin injection into the lacrimal gland in crocodile tears syndrome

Purpose:To determine the efficacy and safety of botulinum toxin injection into the lacrimal gland as a symptomatic treatment of crocodile tear syndrome (CTS).Methods:Our study included six patients of unilateral gustatory hyper lacrimation following either an episode of facial paralysis or post trauma or any related surgery that posed a risk of damaging the facial nerve. Detailed history regarding previous trauma, duration of facial paralysis, previous significant surgery, and duration of steroid use following facial paralysis was noted. Schirmer’s test was done at baseline and 3 months follow-up. Patients’ consent was taken prior to treatment with botulinum toxin injection in the lacrimal gland. Repeat injection of 5 U botulinum toxin (type A) was administered into the lacrimal gland of all patients transconjunctivally within an interval of 1 week. All patients were followed up with Schirmer’s test at 6 weeks and 3 months. Any complications during treatment were recorded.Results:All six patients showed complete or partial disappearance of reflex lacrimation while chewing following botulinum injection measured by a significant reduction in Schirmer’s value. When comparing Schirmer test values before (27.8 ± 3.58 mm) and after (11.6 ± 2.28 mm) BTX-A injection, the differences observed (P = 0.002) were statistically significant (P < 0.05). Only two patients developed mild transitory ptosis. No other complications were notedConclusion:Transconjunctival botulinum toxin injection into the lacrimal gland is an effective and safe method to decrease reflex lacrimation during eating or chewing in CTS or gustatory hyper-lacrimation syndrome.     

Retreatment of children after surgery for acquired esotropia: reoperation versus botulinum injection

AIMS—Two viable options were compared, reoperation and botulinum toxin injection, in the management of children who need retreatment after surgery for acquired esotropia.
METHODS—47 strabismic children previously operated to correct an acquired esotropia were randomised to reoperation or botulinum toxin injection. Reoperation was undertaken in 24 of these patients and botulinum toxin injection in 23 of them. The percentage net change in distance deviation, the percentage of patients with successful motor outcome, detectable fusion, and stereopsis were compared 1 year after retreatment and at last visit (average follow up: 2.9 years in reoperation group, and 2.7 years in botulinum group). The motor success rate relative to time elapsed from initial surgery was evaluated.
RESULTS—There was no significant difference in the motor and sensory outcomes between patients reoperated and treated with botulinum injection. The frequency of correction to within 8 prism dioptres of orthotropia was, respectively: 75% versus 69.56% at 1 year; 70.83% versus 60.86% at last visit. Botulinum injection could be more effective when performed within 3 months of initial surgery.
CONCLUSIONS—Botulinum injection is a rapid and safe procedure that may be as effective as reoperation in the management of children who need a secondary procedure after surgery for acquired esotropia.

Keywords: esotropia; reoperation; botulinum toxin     

Botulinum Toxin Treatment in Patients Up to 3 Years of Age Who Have Esotropic Duane Retraction Syndrome

ABSTRACT

Purpose: To report the results of botulinum toxin (BOTOX®, Allergan) type A (BTA) bilateral injection in the treatment of Duane retraction syndrome (DRS) type 1 in patients aged up to 3 years.

Methods: We studied the results of BTA bilateral injection in eight consecutive patients with DRS type 1 and esotropia in primary gaze. Average follow-up was 74?±?71 months. The main variables analyzed were horizontal and vertical deviation and face turn. Patients were anesthetized with nitrous oxide (N₂O). A mean dosage of 5.6?±?1.8?IU (range 2.5–7.5?IU) of botulinum toxin diluted in 0.9% saline solution was injected under electromyography control in each medial rectus muscle.

Results: Seven patients had one affected eye and one patient had bilateral involvement. The mean preoperative esotropia was 32?±?10 prism diopters (PD). Three patients (37.5%) had also a vertical deviation. All patients had face turn ranging between 15° and 45° before BTA injection. In the last follow-up, 4 patients were orthotropic (50%), 1 (12.5%) had 3 PD exotropia and 3 (37.5%) had esotropia averaging 25 PD mean. The 3 esotropic patients needed surgical correction. Vertical strabismus improved in 3 patients achieving complete resolution in one of these patients. Two patients, without vertical strabismus before the BTA injection, developed a 5-PD vertical deviation, one of them required surgery. Face turn improved in all patients.

Conclusion: Botulinum toxin injection is an alternative treatment for patients with DRS type 1 presents esotropia and face turn in children up to 3 years of age.     

Amblyopia treatment and quality of life: the child’s perspective on atropine versus patching

ABSTRACT

Background: The impact on children of patching versus atropine treatment for amblyopia was assessed using children’s perspective Health-Related Quality of Life (HRQoL) scores in 5 to 7-year olds.

Methods: Forty-six children on the threshold of commencing either patching or atropine treatment for amblyopia were recruited. Treatment was prescribed for uniocular amblyopia of visual acuity (VA) 0.2 logMAR or worse. After four weeks of their chosen treatment, each child completed the Child Amblyopia Treatment Quality-of-Life Questionnaire (CAT-QoL). The Pediatric Quality of Life Inventory (PedsQL?), Young Child (5–7) Self-Report version, was completed before and after four weeks of treatment. Quality of life scores were compared between the two treatment groups.

Results: Sixty-one percent (n = 28) of participants were male and 56.5% (n = 26) were white British. The CAT-QoL has a range of 0–16, with 16 being the worst quality of life. No significant difference was found between the patching group (n = 30, mean age 69.7 months) and the atropine group (n = 16, mean age 69.3 months) for CAT-QoL quality of life scores (Patch median = 6.3, Atropine median = 5.6, U = 199, p = .341, 95% CI of the median difference of ?2.3 to 0.9). The Young Child (5–7) Self-Report version of the PedsQL? has a ‘total score’ range of 0–100, with 0 being the worst quality of life. There was also no significant difference in PedsQL? quality of life total scores (Patch median = 80, Atropine median = 83.33, U = 239.5, p = .991, 95% CI of the median difference ?13.33 to 10) after four weeks of treatment.

Conclusion: Amblyopic children reported that patching and atropine treatments did not have a significant impact on their quality of life. Patching and atropine should continue to be offered as first-line treatments for amblyopia, as children appear to tolerate both well and do not favor one over the other.     

Manejo del estrabismo asociado al glaucoma de la infancia: serie de casos

ObjectiveTo evaluate the different modalities of treatment of the strabismus related to infantile glaucoma, its complications, and results.MethodsThe clinical history of 7 patients with infantile glaucoma which required strabismus surgical treatment were analyzed. Age at onset of glaucoma, type of glaucoma, glaucoma surgeries, type of strabismus, strabismus surgical treatment and postoperative results were studied.ResultsFour patients required strabismus surgery, two were treated with botulinum toxin and one required both. Primary congenital glaucoma was the most common (71,42%), 14,28% had an anterior segment dysgenesis and 14,28% had secondary glaucoma. Regarding strabismus, 4 patients had exotropia and 3 had esotropia. The main difficulty involved the management of the conjunctiva and the filtering blebs.ConclusionStrabismus is a frequent complication in infantile glaucoma. The management of these patients should be individualized. In our case series, treatment of strabismus improved eye alignment. Surgery should be the mainstay of treatment while preserving the conjunctiva and interfere the less with glaucoma surgeries. Botulinum toxin is a reasonable option when conservative treatment is needed.     

A 型肉毒毒素治疗先天性内斜视的疗效观察

目的 观察经结膜内直肌注射A型肉毒毒素（BTXA）治疗先天性内斜视的效果。设计 回顾性病例系列。研究对象 先天性内斜视患儿12例（24眼）,确诊年龄6~34个月（平均19.69±8.61个月）。方法 对所有患儿行眼科常规检查：包括视力、眼前节、眼底、睫状肌麻痹后的屈光度,角膜映光法和三棱镜+交替遮盖法测量33 cm 和6 m 斜视度,有屈光不正者测量裸眼及戴镜斜视度。对不能配合常规三棱镜检查的患儿,使用角膜映光法或Krimsky三棱镜法测量。在肌电放大仪引导下行双眼内直肌注射BTXA 2.5单位,注射后2周,3、6个月,1、2年和末次随访重复注射前各项检查。注射后看远斜视度≤10△作为正位标准。如果复诊到3个月斜视度持续大于20△进行第二次注射。主要指标 视力、屈光度、斜视度检查,双眼视觉功能检查。结果 12例患者就诊时等效球镜度+0.375～+3.625 D,平均（1.88±0.84） D;治疗前斜视度数+20△~+80△（平均47.91△±25.71△）,随访时间4～84个月（平均25.83±13.13个月）。8例行1次双眼内直肌注射,4例行2次双眼内直肌注射。单纯肉毒毒素注射成功率为83.33%（10/12例）。1例于注射后14个月行手术治疗,术后正位。1例注射后残留较小度数（+15△）,配戴压贴三棱镜治疗。末次随访时12例经综合治疗眼位在正常范围,4例获得正常双眼立体视功能。结论 BTXA治疗先天性内斜视短期有效,重复注射有利于维持效果。     

The course of moderate amblyopia treated with atropine in children: experience of the amblyopia treatment study

Purpose

To assess the course of the response to atropine treatment of moderate amblyopia and to assess factors predictive of the treatment response in children 3 years old to younger than 7 years old.

Design

Multicenter, randomized clinical trial comparing atropine and patching (one of the amblyopia treatment studies).

Methods

A total of 195 children 3 years old to younger than 7 years of age with amblyopia in the range of 20/40 to 20/100 from the atropine treatment arm of this trial were enrolled and included in this analysis. At baseline, daily topical atropine was prescribed for the sound eye. During follow-up, a plano spectacle lens was prescribed for the sound eye for patients whose amblyopia had not been successfully treated with atropine alone. Follow-up examinations were performed at 5 weeks, 16 weeks, and 6 months. The primary outcome measure was visual acuity in the amblyopic eye at 6 months.

Results

Mean visual acuity improved from baseline by 1.3 lines after 5 weeks of treatment, by 2.4 lines after 16 weeks, and by 2.8 lines at 6 months. Visual acuity of 20/30 or better and/or 3 or more lines of improvement from baseline was achieved by 75% of the patients. Improvement occurred over the entire range of baseline acuities (20/40 to 20/100) and was not related to patient age (P = .36). Among the 134 patients improving 3 or more lines from baseline, 7% achieved their maximum improvement by 5 weeks and 46% by 16 weeks. Among the 55 patients who did not respond adequately to atropine alone and were prescribed a plano lens for the sound eye, the mean improvement before the use of the plano lens was 1.0 lines, compared with 1.6 lines after prescribing the plano lens (P = .11). None of the demographic or clinical factors assessed was predictive of the response to treatment. A shift in fixation preference at/near from the atropinized sound eye to the amblyopic eye was not required for the amblyopic eye to improve; amblyopic eye acuity improved 3 or more lines in 29 (60%) of the 48 patients who were found to be using the atropinized sound eye on fixation preference testing. A 2 or more line decrease in sound eye visual acuity occurred more frequently when a plano lens was prescribed in addition to atropine (7 of 43, 16%) compared with treatment with atropine alone (4 of 123, 3%; P = .01).

Conclusions

A beneficial effect of atropine is present throughout the age range of 3 years old to younger than 7 years old, and with an acuity range of 20/40 to 20/100. A shift in near fixation to the amblyopic eye is not essential for atropine to be effective in all cases. Sound eye acuity should be monitored when a plano spectacle lens is prescribed for the sound eye to augment the treatment effect of atropine.     

Visual function deficits in children

In the past year, new work on sensory testing in preverbal infants has expanded our knowledge in three areas: 1) visual acuity testing in infants in varying levels of illumination; 2) visual evoked cortical potential-evidence for binocular function in infantile esotropia; and 3) a new time-efficient method to evaluate color vision in newborns and infants. A newly reported sequel to loss of binocularity is the development of A and V pattern strabismus. In another study, loss of fusion, as with acute concomitant esotropia, was shown to be a sign of serious intracranial disease. Regarding motor visual function deficits, new treatments of infantile esotropia syndrome and nystagmus with botulinum toxin type A are presented. Regarding social issues, visual function deficit of abused children and infants born to drug-abusing mothers are presented as a timely reminder that child abuse is still an enormous social problem, and that the visual system is far from exempt from damage.     

Botulinum toxin A in the treatment of concomitant strabismus in children

PURPOSE: To evaluate the results of treatment of esotropia, exotropia and hypertropia with botulinum toxin A. MATERIAL AND METHODS: 72 children with esotropia, exotropia and hypertropia treated with intramuscular injection of botulinum toxin A. RESULTS: Squint angle decreased 76% in children with alternant esotropia, 70% in children with monocular esotropia, 64% in alternant exotropia and 54% in monocular exotropia after treatment with botulinum toxin A. In hypertropia squint angle reduced in 50%. CONCLUSIONS: The use of injections of botulinum toxin A in treatment of concomitant strabismus improves position of eyes, which creates better conditions for development of localization with normal retinal correspondence.     

One-year results after radiotherapy of choroidal neovascularization in age-related macular degeneration

Summary Choroidal neovascularization (CNV) associated with age-related macular degeneration is the major cause of legal blindness in Europe and the USA in patients aged more than 65 years, but Chakravarthy et al. has reported that radiotherapy has a beneficial effect on visual acuity. Methods: Since March 1996 we have treated 56 patients in cooperation with the Department of Radiotherapy at the Technical University in Munich. The total dose with external beam radiotherapy was 16 Gy in 8 fractions, delivered through an anterior oblique axis to spare the lens. Before the treatment and 3, 6 and 12 months after therapy, we performed a standardized visual acuity and contrast-sensitivity test (ETDRS, Pelli Robson Chard) and fluorescin angiography 6 and 12 months after therapy. Results: Twenty-five angiograms showed well-defined CNV and 31 not well-defined CNV. Six months after the treatment 15 patients had stable visual acuity within one line. Twenty-seven patients had lost more than one line of visual acuity. There was no difference between well and not well defined CNV's. One year after treatment the visual acuity remained stable within one line in 4 patients, no patient had an increase of two lines or more and 17 patients lost more then 2 lines of vision. We saw no side effects other than sicca symptoms in 3 patients. Conclusion: In our opinion, these results do not show that radiation treatment has a real beneficial effect on visual acuity. Further randomized studies are needed to demonstrate the efficiency of this treatment for choroidal neovascularization in AMD.      

学龄前儿童假性近视眼292例分析

目的了解学龄前儿童假性近视眼的性质与特点。方法视光门诊中"近视眼"(远视力<1.0、近视力≥1.0、原瞳验光为近视的)4~6岁学龄前儿童292名515眼。除眼科常规检查外,均用1%阿托品眼膏散瞳,每晚涂眼1次,共7天。1周后由专职人员验光。结果292人515眼中,远视478眼,占92.81%,正视11眼(2.14%),混合散光26眼(5.05%)。结论学龄前儿童假性近视眼的屈光基础为远视眼,为调节导致。学龄前儿童应用阿托品散瞳验光。