Subtenon injection of botulinum toxin for treatment of traumatic sixth nerve palsy

PURPOSE: Subtenon injection of botulinum toxin may produce results similar to intramuscular injection of the medial rectus muscle for the treatment of acute traumatic sixth nerve palsy. This study was designed to evaluate the clinical efficacy of subtenon injection and to compare our results with those in previously published reports. METHODS: During 3 years at a single institution, 13 patients with traumatic sixth nerve palsy of less than 6 months' duration were treated with subtenon injection of botulinum toxin. The deviation angles before and after injection were recorded. A distance esotropia of less than 10 prism diopters (PD) in the primary position or absence of diplopia at 3 months was defined as recovery. RESULTS: Of the 13 patients treated, 11 (84.5%) had unilateral palsy and 2 (15.4%) had bilateral palsy. The average pre-injection deviation was 39.5 PD of esotropia, and the average post-injection deviation was 17.0 PD. Seven patients experienced recovery and regained binocular single vision; the overall recovery rate was 53.8% (unilateral, 63.6%; bilateral, 0%). Six patients did not recover and subsequently underwent strabismus surgery. CONCLUSION: Patients with traumatic sixth nerve palsy treated with subtenon injection of botulinum toxin showed higher recovery rates than did most patients treated with conservative measures in published reports. The result of subtenon injection of botulinum toxin without electromyography (EMG) guidance was comparable to that obtained using EMG-guided intramuscular injection of botulinum toxin. Patients with unilateral palsy demonstrated a better recovery rate than did patients with bilateral palsy.     

Surgical correction of excess esotropia at near

A retrospective study of the surgical treatment of patients with excess esotropia at near was conducted. Thirty-one patients conformed to the following criteria: equal vision in each eye, esotropia at near exceeding distant deviation by 15 or more prism diopters, and no prior surgery. Hyperopes greater than or equal to +1.50 spherical equivalent were measured in their full spectacle correction. All patients had an otherwise normal ocular examination and no overt neurological disease. At distance fixation, approximately half of the population had an esotropia greater than 10 delta and the remainder were orthophoric. All demonstrated a near deviation measuring at least 25 delta. Patient age at time of surgery ranged from 18 months to 36 years. All but two patients underwent bilateral medial rectus recessions of 4.5 mm to 7 mm, based on the near deviation. The remaining two patients underwent right medial rectus recessions of 6 mm each. Minimum postoperative follow-up was 4 months. The majority of patients were able to achieve satisfactory alignment. Many could maintain this alignment without spectacles. Two patients developed consecutive exotropia. One of these patients required bilateral lateral rectus recessions to achieve alignment.     

Critical age of botulinum toxin treatment in essential infantile esotropia

PURPOSE: To assess the results of botulinum toxin treatment in 60 consecutive children with essential infantile esotropia. METHODS: Bilateral simultaneous injection of botulinum toxin into the medial rectus muscle was performed in 60 patients under direct visualization with an "open sky" technique. Fluothane/sevoflurane insufflation anesthesia was used. Each patient underwent a single bilateral botulinum toxin injection. Patient age at the time of injection ranged from 5-8 months. RESULTS: Mean patient age at the time of treatment for the 88% of patients who gained a good alignment (within +10 prism diopters [delta] of residual esotropia) was 6.5 months, while mean patient age at time of injection for the 12% of patients who were undercorrected or the deviation relapsed was 7.8 months. Follow-up averaged 5.2 years (range: 2-9 years, SD 2). No variation of the angle of strabismus was observed after 6 months from injection. In some patients with hyperopic refraction, plus lens corrections were prescribed during follow-up to stabilize the alignment. CONCLUSION: Botulinum toxin can be effective in essential infantile esotropia when children are treated by age 7 months.     

Clinical characteristics and surgical treatment of intermittent esotropia

This study describes the age of onset, symptomatology, and clinical characteristics of 25 patients with intermittent esotropia. This subgroup of esotropic patients typically has onset prior to 10 years of age and shows excellent bifoveal fixation ability, reflected by a high degree of stereopsis. In contrast to patients with other forms of esotropia, there is minimal to no hyperopia, an average esodeviation of approximately 20 prism diopters, and a low incidence of amblyopia, DVD, and oblique overaction. Symptomatic diplopia or cosmetic concern necessitated surgical intervention in 17 (68%) patients. Fifteen (88%) patients had good or excellent surgical results of either orthophoria, esophoria, or residual esotropia of 10 delta or less. One patient (6%) had residual esophoria greater than 10 delta. One patient had 4 delta of exophoria postoperatively. Intermittent esotropia should be differentiated from the various entities of microtropia, fixation disparity, and monofixation syndrome.     

Recession of the inferior rectus muscle under topical anesthesia in thyroid ophthalmopathy

PURPOSE: To evaluate the results of inferior rectus muscle recession with adjustable loop suture under topical anesthesia for vertical deviations secondary to thyroid ophthalmopathy. PATIENTS AND METHODS: Five patients with a vertical deviation greater than 15 PD and severe limitation of upgaze were enrolled in the study. Before proceeding with corrective strabismus surgery, we waited at least 6 months after stabilization of ocular alignment and normalization of thyroid chemistries. All patients underwent inferior rectus muscle recession with adjustable loop suture under topical anesthesia. The postsurgical follow-up was at least 12 months. RESULTS: Preoperatively, the mean vertical deviation was 24 PD. At 1 year postoperatively, it had decreased to 2.4 PD. Two patients were orthotropic and 3 patients had residual hypotropia ranging from 2 to 6 PD. The limitation of upgaze was relieved significantly in the postoperative period. Two patients had minimal limitation of downgaze, but none complained of diplopia in the primary or reading positions. Surgery did not trigger a flare-up of orbital inflammation in the early postoperative period. CONCLUSION: We advocate that recession of the inferior rectus muscle with adjustable loop suture under topical anesthesia is safe and effective in patients with thyroid ophthalmopathy.     

Long-term results of bilateral medial rectus recession for congenital esotropia

PURPOSE: This study assessed the long-term results of orthophoria obtained with bilateral medial rectus recession for congenital esotropia. PATIENTS AND METHODS: The medical records of 214 patients who underwent bilateral medial rectus muscle recession between January 1995 and January 2000 were reviewed. Patients were excluded if neurological abnormalities or developmental delays were documented and if structural eye abnormalities were present. Mean follow up was 54.2 months (range, 36 to 96 months). Rates of reoperation for residual esotropia, consecutive exotropia, oblique muscle overaction, or dissociated vertical deviation were determined. RESULTS: Forty-five (21%) patients underwent surgery for residual esotropia, 32 (15%) underwent surgery for consecutive exotropia or dissociated horizontal deviation, and 39 (18%) underwent surgery for oblique muscle overaction and dissociated vertical deviation. CONCLUSION: To maintain long-term alignment of congenital esotropia, additional surgical procedures may be required. The success rate of bilateral medial rectus recession for ocular realignment with one operation is approximately 50%. This method is quicker, simpler, and less traumatic than three or four muscle operations. In addition, the lateral rectus and oblique muscle are left unoperated for future surgeries if necessary.     

Botulinum toxin injection without electromyographic assistance

PURPOSE: To ascertain whether electromyographic control of the muscles when injecting botulinum toxin in the medial rectus muscles of children under sedation is necessary to obtain good results in terms of ocular alignment and postoperative complications. METHODS: Forty neurologically normal children 6 to 48 months of age were entered consecutively into the study once the initial diagnosis of essential infantile esotropia had been made. The children were sedated with sevoflurane and both medial rectus muscles were injected with 7 IU of botulinum toxin using an insulin syringe with a 27-gauge needle. Postoperative controls were performed at 3 days, 3 weeks, 3 months, and 6 months after the injection. The effectiveness of the injection was noted in terms of tropia, paralysis, and associated complications. RESULTS: The mean tropia at 6 months postoperatively was 8.47 prism diopters of esotropia, ranging from 25 prism diopters of esotropia to 10 prism diopters of exotropia. Fifty-three percent of the patients had an esotropia between 0 and 10 prism diopters. The most common complications were ptosis and vertical deviation, affecting 23% and 21% of the patients, respectively, followed by conjunctival hemorrhage, which was recorded in 7% of the patients. There were no retrobulbar hemorrhages, ocular perforations, or anesthetic complications. CONCLUSIONS: If anesthetic risks are higher and the results are similar when using electromyographic control, we advocate not using it in congenital esotropia when injecting botulinum toxin in children.     

Medial rectus re-recession in undercorrected esotropia.

Conventional surgical management of surgically undercorrected esotropia includes bilateral lateral rectus resection, marginal myotomy, and Faden operation. During a 3-year period, 10 patients with surgically undercorrected esotropia had medial rectus re-recession 13.5 mm from the limbus. Successful binocular realignment (to 10 prism diopters or less residual binocular misalignment) was achieved in 9 of the 10 cases for both near and distance measurements.     

Pontine cavernous hemangioma presenting with horizontal gaze palsy

Pontine cavernous hemangioma presenting as horizontal gaze palsy is extremely rare. A 32-years-old patient presented with left horizontal gaze palsy with left esotropia. A large pontine mass was present which was removed in-toto using a sub-occipital craniotomy. Post- operatively, the gaze palsy showed recovery and the diplopia decreased. Follow-up MRI showed no residual mass.     

Benign paralysis of the 6th cranial nerve in children

Acquired sixth nerve palsies in infants and children that occur without fever primarily suggest a tumor or intracranial hypertension. In a few instances, the cause is benign and spontaneous recovery occurs although relapses are occasionally seen. We report seven episodes of benign sixth nerve palsy in four children aged 5 1/2 months to 8 1/2 years. An ENT infection was the precipitating factor in four of these seven episodes. Recovery consistently occurred within 4 days to 6 weeks. None of the children had residual oculomotor impairment. The various etiologic hypotheses put forward in the literature are discussed. No study provides a pathophysiologic explanation for these transient palsies.     

Results of large single medial rectus recession

Fifty-three patients with esotropia of 14 to 20 prism diopters received a 6-mm recession of one medial rectus muscle. All patients were three to ten years of age, had normal, equal vision, no vertical muscle imbalance, normal neurological status, and were followed for a minimum of two years. Twenty patients had high AC/A ratios, 22 were partially accommodative, four were deteriorated esophorias, four were anisometropes, and three were second operations. The average correction measured 16 prism diopters, ranging from 13 to 22 prism diopters, and 37 patients were aligned to 4 prism diopters or less of strabismus, 10 were microtropes, and all 53 had less than 10 prism diopters deviation. No persistent diplopia or consecutive exotropia was encountered. Stereopsis of 200 seconds or better was found in 75% of patients postoperatively. Large single medial rectus recessions appear to be a safe, effective, and predictable means of restoring ocular alignment and binocular vision in a select group of patients.     

Anterior transposition of the superior oblique tendon in the treatment of oculomotor nerve palsy and its influence on postoperative hypertropia

PURPOSE: To determine whether postoperative hypertropia after anterior transposition of the superior oblique tendon without trochleotomy could be avoided with a simplified surgical approach. METHODS: Eight patients with oculomotor nerve palsy (one patient was bilaterally affected) were retrospectively identified as having undergone anterior transposition of the superior oblique tendon without trochleotomy or vertical rectus muscle surgery between March 1992 and September 1998. The superior oblique tendon was cut at the medial border of the superior rectus muscle and placed 1-3.5 mm anterior to the medial insertion of the superior rectus muscle in each of these patients. Resection of the superior oblique tendon was not performed. The lateral rectus muscle was weakened, and no vertical rectus muscles were resected. RESULTS: Preoperative deviations with the uninvolved eye fixating in primary position ranged from 20-90 prism diopters (delta) of exotropia (mean: 49.3 delta) and from 0-20 delta of hypotropia (mean: 11.25 delta). Postoperative horizontal deviations in the primary gaze position ranged from 12 delta of exotropia to 20 delta of esotropia. Six cases were aligned within 10 delta of exotropia or esotropia. Postoperative vertical deviations in the primary gaze position ranged from 2 delta of hypertropia to 8 delta of hypotropia. Six cases were aligned within 2 delta of deviation. Significant postoperative restrictive hypertropia, or new postoperative paradoxical ocular movements, did not occur in any patient. Patients who underwent follow-up >4 months maintained stable eye alignment. CONCLUSION: Transposition of the superior oblique tendon without simultaneous resection or trochleotomy, or additional surgery to the vertical rectus muscle simplifies the surgical technique and eliminates subjective decision making regarding the amount of resection.     

Results of unilateral medial rectus recession in high AC/A ratio esotropia

Twenty-five patients with high accommodative convergence/accommodation (AC/A) ratios and near esotropia of 15 to 35 prism diopters were treated with a 6- to 8-mm unilateral medial rectus recession according to the near deviation. In 24 patients (96%), the esodeviation was aligned within 10 delta, with a follow up ranging from 3 to 7 years. Only one patient had greater than 10 delta of esotropia (14 delta), and none became exotropic. This procedure appears to be a safe and effective method in the treatment of esotropia with high AC/A ratios, in a selected group of patients.     

Seven-millimeter bilateral medial rectus recessions in infantile esotropia

Thirty-six patients with large angle infantile esotropia averaging 74 prism diopters underwent 7-mm bilateral medial rectus recessions by the cul-de-sac approach. Successful horizontal alignment with the initial procedure when measured at the most recent follow-up examination (average 18.2 months postoperatively) was achieved in 27 patients (75%). Five patients (14%) were undercorrected and four patients (11%) were over-corrected. The advantages of the method, as opposed to three or four muscle procedures, are that it is quicker, simpler, and a less traumatic procedure which leaves the lateral rectus muscles unoperated for future surgeries if necessary. This is effective even in very large angle congenital esotropia.     

Incidence of stereopsis after treatment of infantile esotropia with botulinum toxin A

PURPOSE: The incidence of stereoscopic vision following surgery for infantile esotropia has been reported, but not from patients treated with simultaneous bimedial injection of botulinum toxin A. We previously reported other findings from 41 patients treated with botulinum toxin A before the age of 12 months. The purpose of this study was to report the incidence of stereopsis in these patients after long-term follow-up. PATIENTS AND METHODS: Data were acquired by recording the response to subjective stereoscopic testing during the postinjection follow-up period when reliable subjective responses could be obtained. At least 5 years had passed following injection, and the mean age of the patients was 8 years. RESULTS: Of the 41 patients, 11 were lost to follow-up, 10 had no stereopsis, 9 had gross stereopsis (according to Titmus fly tests), 1 had 800 seconds of stereoscopic vision, 2 had 400 seconds, 2 had 200 seconds, 1 had 60 seconds, and 5 had 40 seconds. CONCLUSIONS: In this study, two-thirds of the patients acquired stereopsis following simultaneous bimedial injection of botulinum toxin A for infantile esotropia. Stereopsis acquisition following injection of botulinum toxin A had a success rate comparable with that reported for surgically corrected infantile esotropia. Bimedial injection of botulinum toxin A accompanied by alternate patching prior to injection and diligent attention at ages ranging from 4 to 12 months is a simple and efficacious method for the management of infantile esotropia.     

Arachnoid cyst resulting in sixth nerve palsy in a child

A 2 year old presented with incomitant esotropia and abduction deficit consistent with sixth nerve palsy. Neuroimaging revealed an arachnoid cyst on the left. Neurosurgical shunting followed by strabismus surgery relieved the abduction deficit and esotropia. An arachnoid cyst may be a rare cause of acquired sixth nerve palsy and strabismus in children.     

Neuro-ophthalmic features in pediatric tubercular meningoencephalitis

PURPOSE: To examine the neuro-ophthalmic profile in childhood tubercular meningoencephalitis and assess its prognostic importance. METHODS: One hundred consecutive patients with tubercular meningoencephalitis underwent evaluation for optic nerve functions, supra- and infranuclear oculomotor involvement, and raised intracranial tension. Patients underwent follow-up for 9 months. RESULTS: In 100 patients with tubercular meningoencephalitis, 67 had neuro-ophthalmic features. Common findings were retrobulbar neuritis (32) and gaze palsy (20). Others, in decreasing prevalence, were third and sixth nerve palsy, conjugate deviation, primary optic atrophy, and complete ophthalmoplegia. Raised intracranial tension was associated with neuro-ophthalmic features in 53 of 67 patients (P<.05). Complete ophthalmoplegia was significantly associated with mortality on logistic regression analysis (relative risk, 6.35; P=.012). By 6 months, 56% of patients with retrobulbar neuritis progressed to optic atrophy. CONCLUSION: Neuro-ophthalmic features, in association with raised intracranial tension, often are a part of pediatric tubercular meningoencephalitis presentation. The type of neuro-ophthalmic features may have prognostic value. Optic nerve involvement is the most common finding in tubercular meningoencephalitis.     

Ocular fixation to nasal periosteum with a superior oblique tendon in patients with third nerve palsy

PURPOSE: To report a new surgical approach that uses ocular fixation to the nasal periosteum with superior oblique tendon for patients with complete third nerve palsy. METHODS: Prospective study of 15 patients with complete third nerve palsy who underwent surgery using a superior oblique tenectomy and ocular fixation to the nasal periosteum with the superior oblique tendon fragment. RESULTS: Eleven (73%) patients achieved good ocular alignment, 1 (7%) patient had a cosmetically acceptable result, and 3 (20%) patients had a cosmetically unacceptable result. Five (30%) patients had preoperative diplopia; all achieved resolution of their double vision in the primary position of gaze after surgery. Two patients without preoperative diplopia did not achieve good alignment and had diplopia postoperatively. Follow-up ranged from 8-41 months (mean: 19 months). No operative complications occurred. CONCLUSION: Ocular fixation to the nasal periosteum with superior oblique tendon is a safe, effective, and technically undemanding option for the surgical management of patients with complete third nerve palsy.     

Long-term results of hang-back medial rectus recession

PURPOSE: To report long-term results with the hang-back technique for medial rectus muscle recession. METHODS: Medical records of 341 consecutive patients who underwent unilateral or bilateral hang-back medial rectus recession were reviewed. The amount of recession was based on the size of the esotropia as measured at near fixation. Patients were divided into two groups according to age at onset of esotropia: patients <1 year comprised group 1 and patients > or = 1 year comprised group 2. Surgical outcomes were analyzed for all patients included in the study. RESULTS: A total of 189 patients met the inclusion criteria. In group 1 patients (n=32), average deviation improved from 48.3 prism diopters (PD) preoperatively to 1.1 PD postoperatively. Eleven patients required a second procedure: 9 with recurrent esotropia and 2 with consecutive exotropia. Average time to second procedure was 27.4 months. In group 2 patients (n=157), average deviation improved from 29.6 PD preoperatively to 1.1 PD postoperatively. Twenty-one patients required a second procedure: 20 with recurrent esotropia and 1 with consecutive exotropia. Average time to second procedure was 22.7 months. CONCLUSION: The hang-back technique represents a safe, effective alternative to conventional medial rectus recession.     

The management of esotropia with high AC/A ratio (convergence excess)

This paper reviews the long-term follow-up of esotropia with a high AC/A ratio defined as an increase of 20 delta or more of the esotropia at near compared with distance with the full optical correction of any refractive error in place. Ninety-nine patients were studied for an average follow-up of eight years. Eighty-six achieved fusion but only five achieved central fusion. Forty-five were treated with bifocals. No significant difference in the sensory results were recorded in those patients wearing bifocals compared with those who did not wear bifocals. No patient had miotic therapy for more than a few months. The suppression characteristic of this condition is reviewed.