Three horizontal muscle surgery for large-angle infantile esotropia: validation of a table of amounts of surgery

Purpose

To validate a table of amounts of three horizontal muscle surgery in patients with large-angle infantile esotropia (≥60 prism dioptres, PD).

Methods

A prospective interventional case series reporting the postoperative alignment of 51 patients (27 male, 24 female) over a 15-year period was conducted. Surgery amounts were according to a published table developed on a previous patient cohort (n=49), using bilateral medial rectus recession with graded unilateral lateral rectus resection. Kaplan–Meier life-table survival curves were formulated for success to orthotropia (±10 PD) after one and subsequent horizontal muscle surgeries for up to 8 years follow-up.

Results

The median preoperative deviation was 65 PD (range 60–80 PD) and median age at surgery was 11.8 months (range 5.1 months–3.6 years). Surgical success to orthotropia (±10 PD) after one surgery was 100% at 2 months, 95.7% at 6 months, 91.3% at 12 months, 77.8% at 4 years, and 73.6% at 8 years. Postoperative failure requiring further horizontal surgery occurred in 17.6% (residual esotropia 4, consecutive exotropia 5).

Conclusions

Our second cohort has reproduced the success rate of the previous cohort (77.8% vs 77.1% at 4 years). If the published table of surgical amounts is used, three horizontal muscle surgery in large-angle infantile esotropia (≥60 PD) appears to have a good long-term success rate, and does not lead to the high rates of either residual esotropia or consecutive exotropia reported by others in the literature.     

双眼内直肌超常量后徙治疗大度数内斜视

目的探讨双眼内直肌超常量后徙治疗大角度内斜视的效果。方法30例大度数内斜视的患者，施行双内直肌超常量后徙8～10mm。结果在30例中26例（86．67％）眼位正常或存在10。以内轻度内斜视，4例（13．33％）患者矫正不足而失败。结论双眼内直肌超常量后徙是治疗大度数内斜的有效方法。     

双眼内直肌超常量后退治疗婴幼儿大度数内斜视12例

目的:探讨双眼内直肌超常量后退治疗婴幼儿大度数内斜的效果。方法:12例大度数内斜视的婴幼儿,施行双内直肌超常量后退8mm。结果:在12例中,9例(75%)眼位正常或存在10°以内的轻度内斜视,3例(25%)患儿矫正不足而失败。结论:双眼内直肌超常量后退是治疗婴幼儿大度数内斜的有效方法。     

超常量内直肌后退术治疗大度数内斜视的疗效

目的:观察双眼内直肌超常量后退术治疗大度数非调节性的共同性内斜视的临床效果。方法:回顾分析81例大度数共同性内斜视,按手术方式不同分为观察组(内直肌超常量后退)和对照组(内直肌常规量后退),评价其手术肌肉条数、术后1wk及1a的眼位和眼球内转功能。结果:观察组行双眼内直肌后徙术43例,双眼内直肌后徙+单眼外直肌缩短术5例;对照组行双眼内直肌后徙术6例,双眼内直肌后徙+单眼外直肌缩短术21例,双眼内直肌后徙+双眼外直肌缩短术6例。手术肌肉条数比较两组之间差异有统计学意义(χ2=41.72,P<0.01)。术后1wk,观察组眼位-2△～+12△,平均+6.52△±3.23△,对照组眼位-3△～+10△,平均+5.38△±2.46△,两组比较差异无统计学意义(t=1.45,P=0.08);术后1a,观察组眼位-5△～+10△,平均+4.57△±2.71△,对照组-5△～+8△,平均+3.92△±2.15△,两组比较差异无统计学意义(t=1.23,P=0.10)。术后1wk,观察组有14例,对照组有6例内转功能受限;术后1a,观察组有5例,对照组有2例内转功能受限,两组比较差异均无统计学意义(χ2=1.27,P>0.05;χ2=0.47,P>0.05)。结论:超常量内直肌后退术治疗大度数共同性内斜视可减少手术肌肉条数,他对眼球内转功能无明显影响。     

悬吊缝线后退术矫正内斜视的临床效果

目的 探讨悬吊缝线后退术矫正内斜视的疗效.方法 对内斜视39例(共同性内斜视37例、外伤后周定性内斜视2例)实施内直肌悬吊缝线后退术加外直肌缩短术.结果 术后远期正位35例.正位率89.74%;好转2例.总有效率94.87%.欠矫1例,欠矫率2.56%;过矫1例,过矫率2.56%.无并发症.结论 该术式是一种简便易行、安全有效的方法.     

Plasticity of human motion processing mechanisms following surgery for infantile esotropia

Monocular oscillatory-motion visual evoked potentials (VEPs) were measured in prospective and retrospective groups of infantile esotropia patients who had been aligned surgically at different ages. A nasalward-temporal response bias that is present prior to surgery was reduced below pre-surgery levels in the prospective group. Patients in the retrospective group who had been aligned before 2 yr of age showed lower levels of response asymmetry than those who were aligned after age 2. The data imply that binocular motion processing mechanisms in infantile esotropia patients are capable of some degree of recovery, and that this plasticity is restricted to a critical period of visual development.     

Relation between preoperative hyperopia and surgical outcome in infantile esotropia

AIM: To evaluate the relation between preoperative hyperopia and surgical outcomes of infantile esotropia in patients younger than 24 months of age. METHODS: Medical records of patients who underwent bilateral medial rectus muscle recession for infantile esotropia between November 1, 2002 and December 1, 2011 were retrospectively reviewed. Patients were divided into two groups according to the degree of preoperative hyperopia. Group I had less than +3.0 diopter (D) of hyperopia and group II had between +3.0 and +5.0 D of hyperopia. Postoperative alignments were evaluated 1wk, 3, 6mo, and 1y after surgery. Following the 1-year postoperative visit, patients were monitored yearly. Relationships between preoperative factors including hyperopia and postoperative outcomes were evaluated. RESULTS: Forty-six patients were included, with 33 patients in group I and 13 patients in group II. The preoperative mean refractive error was +0.88 D in group I and +3.45 D in group II. Surgical outcomes were not significantly different between groups at any postoperative time point examined. Cumulative probability of surgical success, prevalence of inferior oblique overaction, dissociated vertical deviation, and re-operation rate were not significantly different between groups. CONCLUSION: Preoperative moderate hyperopia (less than +5.0 D) did not affect the surgical outcome of infantile esotropia. Therefore, the surgical correction of esotropia should be considered when the angle of esodeviation is unchanged following hyperopia correction, even in children with moderate hyperopia.     

The relationship between abduction deficit and reoperation among patients with infantile esotropia

AIM: To determine the relationship between abduction deficit and reoperation among patients with infantile esotropia (IET). METHODS: The records of 216 patients (432 eyes) with IET who underwent surgery, from 2010 to 2015 were studied. Patients with IET whose deviation appeared before 6mo of age and had stable preoperative deviation in two examinations with at least 2wk apart and a minimum 3mo postoperative follow up were included. Cases with early onset accommodative esotropia, congenital cataract, retinopathy of prematurity (ROP), manifest nystagmus, fundus lesions, neurologic and ophthalmic anomalies, 6th nerve palsy and Duane’s syndrome were excluded. Preoperative abduction deficit was considered from -1 to -3 grading scale. Three months after surgery, children were classified into no-need reoperation [deviation≤15 prism diopters (PD)], and need-reoperation groups (deviation>15 PD). RESULTS: In this retrospective study, 117 female and 99 male patients with the mean surgical age of 4.7±6.4y were included. Reoperation rate was 33.3% and 16.0% in IET patients with and without abduction deficit, respectively in patients who had a history of late surgery. Abduction deficit increased the odds of reoperation by 82% [OR=1.82, 95% confidence interval (CI) =1.05 to 3.19, P=0.003] in patients who had a history of late surgery (>2 years old, P=0.021). Abduction deficit was improved significantly after operation (P<0.001). CONCLUSION: Based on our results, abduction deficit can be considered as a risk factor of reoperation in IET patients who are operated at the age of more than 2y.     

直角三棱镜和等腰三棱镜测量斜视角的比较

目的:探讨直角三棱镜和等腰三棱镜测量斜视角的差异。方法:病例对照研究,选取2021-06/2022-04我院住院共同性斜视患者176例,其中共同性内斜视患者79例,共同性外斜视患者97例。所有患者分别运用交替遮盖直角三棱镜和等腰三棱镜中和法进行斜视角测量。结果:共同性内斜视患者直角三棱镜测量结果为49.167^△±13.573^△,等腰三棱镜测定结果为38.250^△±10.756^△(P<0.01),两者差值为10.917^△±3.752^△;直角三棱镜测量值转换为圆周度为19.096°±2.456°,等腰三棱镜为20.847°±5.364°(P<0.05),两者差值为2.443°±2.702°;共同性外斜视患者直角三棱镜测量结果为51.875^△±13.567^△,等腰三棱镜测量结果为40.492^△±11.753^△(P<0.01),两者差值为11.383^...     

A型肉毒毒素与眼外肌手术治疗大角度急性共同性内斜视的疗效对比

目的：探讨A型肉毒毒素(BTA)注射和眼外肌手术治疗大角度(≥+60 PD)急性共同性内斜视(AACE)的疗效差异性。

方法：回顾性分析2020-06/2022-12于我院治疗的AACE患者60例的临床资料,根据治疗方式分为2.5 IU BTA注射组(14例)、5.0 IU BTA注射组(29例)、手术组(17例)。治疗后随访6 mo,观察纳入患者屈光矫正后的斜视度、视功能、治疗有效率及BTA注射后并发症发生情况。

结果：治疗后6 mo,手术组和5.0 IU BTA注射组患者的斜视度均小于2.5 IU BTA注射组(P<0.017),但手术组与5.0 IU BTA注射组患者的斜视度无显著差异(P>0.017); 5.0 IU BTA注射组有效率高于2.5 IU BTA注射组(86% vs 43%,P<0.017); 三组患者各级视功能均无差异(P>0.05); 2.5 IU BTA注射组和5.0 IU BTA注射组治疗后并发症总发生率无显著差异(43% vs 52%,P>0.05)。

结论：对于斜视度≥+60 PD的AACE患者,双眼内直肌注射5.0 IU BTA可以取得与传统眼外肌手术相当的效果,且其具有创伤小,操作简单方便的优势。     

Essential infantile esotropia with inferior oblique hyperfunction: long term follow-up of 6 muscles approach

AIM: To evaluate long term follow-up (10y) of 6 muscle surgical approach in essential infantile esotropia (EIE). METHODS: A 6 muscle approach to EIE was retrospectively evaluated in patients with inferior oblique (IO) hyperfunction and lateral rectus (LR) pseudoparalysis, who underwent surgery at different ages. Different clinical characters were analyzed pre- and postoperatively, in patients who underwent a 6 muscles approach ≤4 years of age. All patients underwent a multiple muscles approach: bilateral medial recti (MR) recession (4-5 mm), bilateral LR resection (lower than 7 mm) and bilateral IO recession and anteroposition. Of 108 children with preoperative angle ≥+30 prism diopters (PD) and IO hyperfunction were selected from larger cohort of patients (n=213, 103 females and 110 males) after excluding patients with: angle variability, who underwent reoperation and with incomplete follow up. Preoperative assessment and complete orthoptic examination were performed. Follow-up was performed 3mo, 2, 5 and 10y after surgery. Statistical analysis was performes using SAS statistical software package (version 9.1, SAS Institute Inc., Cary, NC, USA). RESULTS: Ten years follow up data analysis showed the following percentage of orthotropic patients: (0 PD): 3mo, 22.2%; 2y, 16.7%; 5y, 25.0% and 10y, 27.8%. A slight, significant (P<0.01), increase of 2y follow up residual deviation was found when compared to 3mo one. Stationary surgical results is reported during time, with a trend of mean residual deviation reduction (P=0.04). CONCLUSION: Our results confirm the reliability of multiple muscles surgical approach in the treatment of patients affected by EIE with OI hyperfunction.     

Surgical outcomes for esotropia in children with high accommodative convergence/accommodation ratio

Purpose:To assess if high accommodative convergence/accommodation (AC/A) ratio impacts surgical outcomes in children with esotropia (ET), and evaluate the appropriate target angle in surgical dosing in the presence of high AC/A ratio.Methods:A retrospective chart review identified patients who underwent primary bilateral medial rectus (BMR) recessions for ET. Patients were excluded if follow-up was ≤2 months. Basic demographic information, visual acuity, stereopsis, alignment, and target angle for surgery were collected. High AC/A was defined as ≥10 prism diopter (Δ) deviation at near compared to distance. Outcome parameters were near and distance deviations ≤10Δ within orthophoria, and/or stereopsis postoperatively. Yates’ continuity correction, unpaired t-test, regression analysis, and one-way ANOVA were used.Results:We identified 103 patients, 23 with high AC/A and 80 with normal AC/A, preoperatively. Mean age was 4.0 ± 2.5 years. Surgical success measured by postoperative alignment was 48% and 45% in the high AC/A and normal AC/A groups, respectively (P = 1.0). There was a statistically significant difference in preoperative near deviation between high AC/A and normal AC/A groups (P = 0.0015); however, there was no significant difference in preoperative distance deviation (P = 0.061). In addition, there was not a significant difference in preoperative or postoperative stereopsis between high AC/A and normal AC/A groups (P = 0.88 and P = 0.44, respectively). There was a significant difference in the normal AC/A and high AC/A groups when target angle was directed toward preoperative near deviation as determined by one-way ANOVA (F = 170.88, P < 0.0001 and F = 14.61, P = 0.0010, respectively).Conclusion:In the setting of ET treated with BMR recession, the presence of high AC/A does not affect surgical success as measured by alignment and stereopsis. In addition, when high AC/A is present, surgical dosing with a target angle toward near deviation was found to yield the best surgical outcomes in our patient population.     

Diffusion tensor imaging of horizontal extraocular muscles in patients with concomitant and paralytic esotropia

AIM: To assess metrics of diffusion tensor imagining (DTI) in evaluating microstructural abnormalities of horizontal extraocular muscles (EOM) in esotropia.METHODS: Six adult concomitant esotropia patients, 5 unilateral abducent paralysis patients and 2 healthy volunteers were enrolled. Conventional magnetic resonance imaging (MRI) and DTI were performed on all subjects using 3T MR scanner. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) of medial and lateral rectus muscles were measured and compared between patients group and control group.RESULTS: Medial rectus MD and RD within the adducted eye of concomitant patients was significantly greater than that in unilateral abducent paralysis patients (0.259×10-2 mm2/s vs 0.207×10-2 mm2/s, P=0.014; 0.182×10-2 mm2/s vs 0.152×10-2 mm2/s, P=0.017). Both strabismus patients showed a significantly decreased MD and AD than that obtained in normal controls for lateral rectus muscles (P<0.05). Medial rectus MD of the adducted eye in concomitant strabismus patients was significantly decreased than that in healthy controls (0.259×10-2 mm2/s vs 0.266×10-2 mm2/s, P=0.010). Lateral rectus AD of the adducted eye in concomitant strabismus patients was significantly decreased as compared with that in healthy controls (0.515×10-2 mm2/s vs 0.593×10-2 mm2/s, P=0.013). No statistically significant differences were present between the adducted and fixating eyes in concomitant strabismus patients.CONCLUSION: DTI represents a feasible technique to assess tissue characteristics of EOM. The effects of eye position changes on DTI parameters are subtle. Decreased MD and RD could be evidence for remodeling of the medial rectus muscle contracture. Lower medial and lateral recuts MD of concomitant esotropia patients indicates a thinner fibrous structure of the EOM. Lower MD and AD should be general character of esotropia.     

Combined horizontal rectus muscle minimally invasive strabismus surgery for exotropia

Objective: To evaluate combined horizontal rectus muscle minimally invasive strabismus surgery (MISS) for exotropia.Design: Case series.Participants: Fifty-two consecutive exotropic patients operated on by 1 surgeon with MISS combined unilateral lateral rectus muscle recession and medial rectus muscle plication.Methods: Alignment, binocular single vision, conjunctival injection and swelling, and complications during the first 6 postoperative months were recorded prospectively. Conjunctival swelling and injection on the first postoperative day were scored retrospectively and compared with historic controls operated on with combined recession-plication or recession-resection using a limbal approach.Results: Conjunctival swelling and injection were mainly mild on the first postoperative day and less pronounced than after surgery with a limbal approach (comparison of swelling and injection for MISS vs limbal opening recession-plication p < 0.001 and for MISS vs limbal opening recession-resection p < 0.001). A conversion to a limbal approach was necessary in 3/104 (3%, 95% CI 1%-7%) of all muscles. No scleral perforation or other serious complication was observed, and no patient needed a repeat operation within 6 months (0/49, 0%, 95% CI 0%-6%).Conclusions: This study demonstrates that small-incision, minimal dissection combined recession-plication surgery induces less conjunctival swelling and injection compared with the usual limbal approach.     

Predictive Value of Age,Angle, and Refraction on Rate of Reoperation and Rate of Spontaneous Resolution in Infantile Esotropia

In the Early vs. Late Infantile Strabismus Surgery Study (ELISSS), 13.5% of children operated at 20 months vs. 3.9% of those operated at age 4 had gross binocular vision (Titmus Housefly). Reoperation rates were 28.7% in the former vs. 24.6% in the latter group and, although all were eligible for surgery at baseline at 11 SD 3.7 months, 8% in the early group vs. 20% in the late group were never operated, mostly because their angle decreased spontaneously. We assessed the predictive value of age, angle, and refraction in these matters.

Methods: The ELISSS reoperation rates were first compared with those found in nine series of consecutive cases in nine university clinics operated during one particular year, between 6 and 23 years previously. Logistic regression was used to estimate the effect of postoperative angle and clinic on the chance of reoperation. Secondly, a meta-regression analysis was done of these and other reported reoperation rates. The mean age at operation and the mean duration of follow-up were regressed on the logistically transformed reported reoperation rates. Finally, to estimate the chance of spontaneous decrease of the angle without surgery, a random-effects model was fitted on the 6-monthly orthoptic measurements of angle and refraction in the ELISSS that antedated surgery, loss to follow-up, or final examination. In the random-effects model (see online-only supplement link or visit, www.simonsz.net), for ELISSS patients the random effect was defined as the deviation of the average angle, the fixed effect. A vector was defined based on age and spherical equivalent of the patient. The variance around the prediction consisted of uncertainty in the estimations, random effects, and residuals.

Results: In the retrospective study, 204 patients who had been first operated between 6 and 23 years previously were eligible. A reoperation had been performed in 32 (19.3%) of the remaining 166 children who were 4.33 SD 1.35 years old at first surgery. The reoperation rate was 7.3% for those with a postoperative angle of ?4° to +4° (N?=?82), 25% for postoperative divergence > 5°, and 29% for postoperative convergence 10° to 14°. Strabismologists overestimated the reoperation rates at double. In the meta-regression analysis, 12 studies were included. Reoperation rates were between 60% and 80% for children first operated around age 1 and approximately 25% for children operated around age 4 (best fit: ?0.221 Ln [age in months] + 1.1069; R²?=?0.5725). Finally, in the predictions of random-effects model, a small angle at age 1 and hyperopia of approximately +4 increased the chance of spontaneous decrease of the angle into a microstrabismus.

Discussion: The benefit of early surgery for gross binocular vision is balanced by a higher reoperation rate and an occasional child being operated that would have had a spontaneous decrease into a microstrabismus without surgery. The fact that, in the ELISSS, hyperopia was associated with a decrease of the angle underscores the benefit of early refractive correction.     

儿童外斜视术后继发性内斜视的手术效果短期观察

目的 探讨儿童外斜视术后继发性内斜视的特点及原因,评价手术治疗效果。设计 回顾性病例系列。研究对象 17例外斜视术后继发性内斜视并再次手术的患儿。方法 总结17例患者既往外斜视手术方法和特点,外斜视术后出现内斜视时间、术后处理、继发性内斜视手术方式以及手术中探查发现。选择间歇性外斜视50例作为对照组,以探讨继发性内斜视的原因。主要指标 第一次手术外斜视的类型、手术方法、术后处理,继发性内斜视出现的时间。第二次手术探查发现、是否合并其他类型的斜视、手术方式以及手术后眼位。结果 17例患者合并垂直斜视9例（52.9%）,其合并中V征2例,合并DVD 4例;而对照组合并垂直斜视者9例（18.0%）,两者比较差异有统计学意义（X2=6.33,P=0.01）。继发性内斜视出现时间为术后1~12个月,平均2个月。继发性内斜视患者16例为恒定性内斜视,1例为不典型周期性内斜视;17例中外展受限10例,手术探查发现肌肉滑脱2例,粘连综合征3例,3例术后进行缝线调整。17例患者治愈14例（82.3 %）,2例过矫,1例欠矫。结论 继发性内斜视平均在外斜视术后2个月出现,外展受限、粘连综合征、肌肉滑脱以及合并垂直斜视为继发性内斜视可能的病因,合并垂直斜视的复合斜视在手术后更容易出现继发性内斜视。（眼科, 2013, 22： 327-331）     

Surgical outcomes and occurrence of associated vertical strabismus during a 10-year follow-up in patients with infantile esotropia

Purpose:Authors analyzed long-term surgical outcomes of infantile esotropia and the occurrence of associated strabismus, inferior oblique overaction (IOOA), and dissociated vertical deviation (DVD). Clinical factors related to the occurrence of IOOA and DVD in patients with infantile esotropia were also evaluated.Methods:Medical records of patients with infantile esotropia, who underwent surgery between 1995 and 2008, were reviewed retrospectively. Included patients were followed for at least 10 years. The incidence and age at development of IOOA and DVD were analyzed. To evaluate predisposing factors for developing IOOA or DVD, patients were divided into two groups: those with infantile esotropia only (group A) and those who developed IOOA or DVD (group B).Results:A total of 122 patients were enrolled and mean follow-up period was 16.0 years (range: 10–32 years). The mean number of surgeries was 1.7 (range: 1–5), and 64 (52.5%) patients achieved optimal horizontal alignment (esotropia <10 prism diopters [PD] and orthotropia). Fifty (41.0%) patients developed IOOA at a median age of 3 years (range: 1–21 years); 54 (44.3%) developed DVD at a median age of 5 years (range: 1–25 years). Patients in group B underwent more horizontal surgeries than those in group A (P = 0.028), and favorable surgical outcomes between the two groups were not different at final visit. There were no other significant differences in clinical factors between the two groups.Conclusion:Approximately, 52.5% of patients achieved favorable surgical outcomes through 1.7 surgeries during the 10-year follow-up period. DVD tended to develop at a later age than IOOA, and in some cases, up to 20 years after diagnosis of infantile esotropia. To achieve favorable horizontal alignment at final visit, patients with associated vertical strabismus underwent more horizontal muscle surgeries than patients with infantile esotropia only. The presence of IOOA/DVD may affect horizontal alignment outcomes.     

Consecutive exotropia after surgical treatment of childhood esotropia: a 40‐year follow‐up study

Purpose: To determine the incidence of consecutive exotropia (XT) following successful surgical correction of childhood esotropia (ET) and identify factors associated with its development. Material and Methods: This is a retrospective study of 85 patients with ET, aged 2–24 , who underwent strabismus surgery by a single surgeon between 1958 and 1969 in Sweden, until they were successfully aligned to ET within 10 prism dioptre, after primary or reoperation(s). The charts of these patients were reviewed, and data regarding age at onset of strabismus, surgery performed and outcome were recorded. The patients were recalled for a complete orthoptic examination in 2001–2003. Results: The incidence of consecutive XT in this cohort was 21% (18/85). Patients who had undergone multiple surgeries had a higher risk of developing consecutive XT compared to those successfully aligned with one surgery (p = 0.00036). Restriction of adduction and convergence postoperatively was associated with a high risk of consecutive XT (p = 0.0437). The incidence of consecutive XT did not vary with the level of visual acuity in the operated eye (p = 0.6428). Age of onset, age at surgery and amount of surgery did not appear to influence the risk for developing consecutive XT (p > 0.05). Conclusion: This 40‐year postoperative follow‐up of patients with childhood ET who underwent strabismus surgery by a single surgeon in Sweden showed that multiple surgeries and presence of postoperative adduction deficit were the most important factors influencing the incidence of consecutive XT after surgery. Presence of uncorrected amblyopia did not alter the prognosis for long‐term development of consecutive XT.     

Occlusion therapy for strabismic amblyopia

Objective : To assess the outcome of occlusion therapy in strabismic amblyopia. Methods : The case notes of 369 children requiring strabismus surgery were reviewed. Results : Of 369 children requiring surgical correction for strabismus, 109 had strabismic amblyopia. All of these patients were treated with occlusion. Seventy-eight per cent (85 of 109) had improvement of their visual acuity to within one Snellen line of the other eye. Another 11% (12 of 109) of patients genuinely failed to achieve equal acuity in both eyes despite occlusion and 11% (11 of 109) failed to improve due to poor compliance. Conclusions : Occlusion for six hours per day, every day, produced an effective and rapid response in most patients. There was no occlusion amblyopia. Admission to hospital for occlusion was effective in some refractory cases.     

Botulinum toxin injections combined with or without sodium hyaluronate in the absence of electromyography for the treatment of infantile esotropia: a pilot study

Objective

To evaluate the feasibility and safety of a revised technique of botulinum toxin type A (BTA) injections for the treatment of infantile esotropia.

Methods

Forty-seven patients with infantile esotropia were randomly divided into two groups. In group A, 23 cases were treated with a bilateral injection of 2.5–3.75 U BTA combined with sodium hyaluronate (SH) to the medial rectus muscle. In group B, 24 cases were treated with a bilateral injection of 2.5–3.75 U BTA solution alone to the medial rectus muscle. Electromyography was not used in the study. All patients received one injection and were evaluated 2 weeks, 3 months, and 6 months following injection.

Results

The measured changes between groups A and B included the frequencies of good alignment 6 months after injections (30.4% vs 37.5%), complicated ptosis (2.2% vs 20.8%), and vertical deviation (2.2% vs 2.1%).

Conclusion

BTA injections combined with or without SH in the absence of electromyography demonstrated effectiveness and feasibility in the treatment of infantile esotropia. A relative decrease in the frequency of complicated ptosis resulted from injections of BTA+SH.