Role of Botulinum Toxin A in Diplopia following Orbital Decompression

Diplopia following orbital decompression is a common complication in Graves' ophthalmopathy. Strabismus surgery is often required to treat the persistent diplopia. The author presents a successful treatment with botulinum toxin A injection in a case of diplopia following orbital decompression. Treatment with botulinum toxin A in the management of new-onset diplopia following orbital decompression has been suggested in a case that is not amenable to prism treatment and may eliminate strabismus surgery in some cases.     

Botox® after Botox® - a new approach to treat diplopia secondary to cosmetic botulinic toxin use: case reports

A new technique for the treatment of diplopia secondary to cosmetic botulinum toxin A use is described. In this interventional case reports, two consecutive patients who developed diplopia after periocular cosmetic use of botulinum toxin A were treated with intramuscular botulinum toxin A injection into the antagonist extraocular muscle. Diplopia resolved in both patients in less than 1 week with no side effects or complications. In conclusion, the injection of intramuscular botulinum toxin A is an encouraging option for treatment of diplopia secondary to botulinum toxin A use for facial lifting.     

Deep lateral wall orbital decompression following strabismus surgery in patients with Type II ophthalmic Graves’ disease

Purpose: Surgical management of ophthalmic Graves’ disease traditionally involves, in order, orbital decompression, followed by strabismus surgery and eyelid surgery. Nunery et al. previously described two distinct sub-types of patients with ophthalmic Graves’ disease; Type I patients exhibit no restrictive myopathy (no diplopia) as opposed to Type II patients who do exhibit restrictive myopathy (diplopia) and are far more likely to develop new-onset worsening diplopia following medial wall and floor decompression. Strabismus surgery involving extra-ocular muscle recession has, in turn, been shown to potentially worsen proptosis. Our experience with Type II patients who have already undergone medial wall and floor decompression and strabismus surgery found, when additional decompression is necessary, deep lateral wall decompression (DLWD) appears to have a low rate of post-operative primary-gaze diplopia.

Methods: A case series of four Type II ophthalmic Graves’ disease patients, all of whom had already undergone decompression and strabismus surgery, and went on to develop worsening proptosis or optic nerve compression necessitating further decompression thereafter. In all cases, patients were treated with DLWD. Institutional Review Board approval was granted by the University of Kansas.

Results: None of the four patients treated with this approach developed recurrent primary-gaze diplopia or required strabismus surgery following DLWD.

Conclusions: While we still prefer to perform medial wall and floor decompression as the initial treatment for ophthalmic Graves’ disease, for proptosis following consecutive strabismus surgery, DLWD appears to be effective with a low rate of recurrent primary-gaze diplopia.     

Strabismus in adults with uveal melanoma following episcleral plaque brachytherapy

PURPOSE: To ascertain the incidence of persistent strabismus in patients treated with plaque brachytherapy and its subsequent treatment. METHODS: A single center retrospective case note review of adult patients with persistent diplopia or strabismus following plaque brachytherapy for all types of intraocular tumors between 1996 and 2004. RESULTS: A total of 929 consecutive adults underwent plaque brachytherapy during the study period at a single center. Sixteen patients (1.7%) with treated uveal melanoma developed persistent diplopia or strabismus. In 11 patients (69%) the timing of onset was in the first year, in 2 (13%) in the second year, and one each (6% each) in years 5, 7, and 8. Two patients (13%) did not require any intervention. Fourteen patients (88%) required treatment: 7 (50%) were treated with prisms only, 3 (21%) underwent botulinum toxin (BTXA) injections, and 4 (29%) were treated with extraocular muscle surgery (3 required one operation and one required 2 procedures). CONCLUSIONS: The incidence of ocular motility disorders following plaque brachytherapy in our cohort was 1.7% over 8 years and we include this in the consent process for conservative treatment of intraocular tumors. Options for treatment for persistent diplopia or strabismus include prisms, botulinum toxin injection, or surgery.     

Optic neuropathy associated with botulinum A toxin in thyroid-related orbitopathy

PURPOSE: To report the development of optic neuropathy after botulinum A toxin injection for restrictive myopathy from thyroid-related orbitopathy (TRO). METHODS: We retrospectively reviewed the records of three patients with TRO who underwent botulinum A toxin injection for restrictive myopathy and subsequently developed optic neuropathy. Development of optic neuropathy was measured by visual acuity, color vision testing, visual field testing, and relative afferent pupillary testing. RESULTS: At 3 week follow-up after botulinum A toxin injection, three patients were noted to have clinical signs and symptoms of optic neuropathy in the ipsilateral eye following injection of botulinum A toxin for restrictive myopathy. Treatment with oral steroids followed by orbital wall decompression reversed the optic neuropathy. CONCLUSIONS: To our knowledge, this is the first report of optic neuropathy associated with botulinum A toxin injection in TRO. Clinicians should be aware of this potential vision threatening complication.     

Recession–resection combined with intraoperative botulinum toxin A chemodenervation for exotropia following subtotal ruptured of medial rectus muscle

Background Ruptured extraocular muscle loses its function and shows severe restriction of eye movement even after muscle-to-muscle anastomosis or muscle transposition surgery. We present the case of a patient who developed a large exotropia after near-total rupture of the medial rectus muscle following a blowout fracture.Methods Case report.Results A 12-year-old girl presented at our clinic with 45 prism diopters’ exotropia after a blunt trauma. A forced duction test was unrestricted, and orbital computed tomography showed a medial orbital wall fracture and an impinged medial rectus muscle. Upon surgical exploration, an almost totally ruptured medial rectus muscle was found. The median margin of the ruptured muscle was 6.0 mm from its insertion, and the distal end that we could examine was 15.0 mm from the limbus. Recession–resection surgery combined with intraoperative botulinum toxin A chemodenervation to the ipsilateral lateral rectus muscle achieved a good primary alignment and binocular single visual field, even at a 9-month follow-up.Conclusions Recession–resection surgery augmented by intraoperative botulinum toxin A chemodenervation to the ipsilateral rectus muscle appears to be highly effective in the treatment of a large exotropia produced by subtotal rectus muscle rupture following orbital wall fracture, with a lower risk of anterior segment ischemia.     

A single transcutaneous injection with Botox for dysthyroid lid retraction

PURPOSE: To evaluate the safety and efficacy of injections with botulinum toxin type A (BTTA,Botox), given transcutaneously, in the treatment of upper lid retraction associated with thyroid eye disease (TED). METHODS: A total of 15 patients (21 eyes) with a stable (TED) condition, and a euthyroid state, were enrolled into the study. There were 12 females and three males from ages 23 to 52 years. A single injection, at the centrally superior tarsal border transcutaneously, aiming at the levator aponeurosis and Müller muscle, was administered into each eyelid with 5-6 U of Botox. All patients were followed regularly for 4-6 months. Any complications, such as ptosis, diplopia, pain,or lid ecchymosis were recorded. RESULTS: All patients, except one, experienced much reduction of palpebral fissure. The mean difference of MRD1 between pre- and postinjections of Botox at the first week was -3.1 mm, and the effect remained, at least, for 2 months. There were temporary complications of ptosis in three patients and vertical diplopia in two patients, lasting 3-4 weeks. CONCLUSIONS: A single transcutaneous injection with Botox for the treatment of thyroid lid retraction is safe and effective. Some minor complications may occur, such as ptosis and diplopia; however, it may offer an alternative and temporary method for patients with dysthyroid lid retraction, who are waiting for a staged operation of either an orbital decompression or a strabismus surgery or both.     

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.     

Transcaruncular orbital decompression for dysthyroid optic neuropathy

PURPOSE: To determine the efficacy of transcaruncular approach orbital apex decompression for treatment of dysthyroid optic neuropathy. METHODS: In this retrospective noncomparative interventional case series, charts for all patients undergoing orbital decompression surgery for dysthyroid optic neuropathy performed by one author between October 1999 and September 2001 were included in the study. Primary outcome measures included visual acuity, static perimetry, pupillary testing, and color plate testing before and after surgery. Records were also reviewed for changes in extraocular motility and proptosis after surgery and for surgical complications. RESULTS: Sixteen consecutive patients (6 unilateral, 10 bilateral, for a total of 26 cases) underwent orbital apex decompression for dysthyroid optic neuropathy through a transcaruncular approach. In each orbit, the optic neuropathy was refractory to oral corticosteroid therapy. Preoperative visual acuity remained stable or improved in each case. Preoperative Humphrey visual field testing revealed an average mean deviation of -10.3 +/- 6.5 (range, +0.76 to -25.45). Average postoperative mean deviation was -2.79 +/- 2.4 (range, +0.94 to -9.82). Before surgery, 7 of 23 eyes (30%) had full color plates. After surgery, 22 of 23 eyes (96%) had full color plates. Follow-up ranged from 2 to 26 months (mean, 10 months). New-onset diplopia developed in 2 of 10 (20%) patients without preexisting diplopia. CONCLUSIONS: Transcaruncular approach orbital apex decompression effectively treats dysthyroid optic neuropathy.     

Clinical course and prognosis of diplopias after orbital bony wall decompression for thyroid related orbitopathy

INTRODUCTION: The aim of this study was to assess how oculomotor complications progress after orbital bony decompression for dysthyroid orbitopathy and to assess the residual risk of consecutive diplopia. MATERIAL AND METHODS: The medial orbital wall and floor were decompressed by a transpalpebral approach in 77 patients (117 orbits). Indications for decompression were optic neuropathy in 22 patients, exposure of the cornea in 1 patient, and cosmetic rehabilitation in 54 patients. Occurrence of oculomotor disorder after surgery was noted and the clinical course after a one-year follow-up was studied. RESULTS: Diplopia was observed in 34 patients (44%): 18 of these patients were treated by external orbital radiotherapy before surgery. Diplopia decreased spontaneously over a period ranging from 15 days to 2 months or was treated by adequate prism in 22 cases. A higher degree of diplopia (12 to 30 diopters) was noted in 12 cases, requiring surgical care that was successful in all cases. This progress was especially observed in patients with optic neuropathy or in patients who had been previously treated with external orbital radiotherapy. CONCLUSION: Prognosis of diplopia after bony wall decompression for thyroid-related orbitopathy can be favorable with spontaneous reduction, prism, or surgical treatment. Precise information should be given to the patients before surgery.     

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.     

Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno

AIMS: A modified surgical technique is described to perform a one, two, or three wall orbital decompression in patients with Graves' ophthalmopathy. METHODS: The lateral wall was approached ab interno through a "swinging eyelid" approach (lateral canthotomy and lower fornix incision) and an extended periosteum incision along the inferior and lateral orbital margin. In addition, the orbital floor and medial wall were removed when indicated. To minimise the incidence of iatrogenic diplopia, the lateral and medial walls were used as the first surfaces of decompression, leaving the "medial orbital strut" intact. During 1998, this technique was used in a consecutive series of 19 patients (35 orbits) with compressive optic neuropathy (six patients), severe exposure keratopathy (one patient), or disfiguring/congestive Graves' ophthalmopathy (12 patients). RESULTS: The preoperative Hertel value (35 eyes) was on average 25 mm (range 19-31 mm). The mean proptosis reduction at 2 months after surgery was 5.5 mm (range 3-7 mm). Of the total group of 19 patients, iatrogenic diplopia occurred in two (12.5%) of 16 patients who had no preoperative diplopia or only when tired. The three other patients with continuous preoperative diplopia showed no improvement of double vision after orbital decompression, even when the ocular motility (ductions) had improved. In the total group, there was no significant change of ductions in any direction at 2 months after surgery. All six patients with recent onset compressive optic neuropathy showed improvement of visual acuity after surgery. No visual deterioration related to surgery was observed in this study. A high satisfaction score (mean 8.2 on a scale of 1 to 10) was noted following the operation. CONCLUSION: This versatile procedure is safe and efficacious, patient and cost friendly. Advantages are the low incidence of induced diplopia and periorbital hypaesthesia, the hidden and small incision, the minimal surgical trauma to the temporalis muscle, and fast patient recovery. The main disadvantage is the limited exposure of the posterior medial and lateral wall.     

Botulinum toxin in the management of acquired motor fusion deficiency

Acquired disruption of motor fusion is a rare condition characterized by intractable diplopia. Management of these patients is extremely difficult. Prisms in any combination or even surgery may not help relieve their symptoms. We describe a longstanding case of acquired motor fusion disruption which was managed successfully with botulinum toxin injection.     

Efficacy and side effects of 'swinging eyelid' orbital decompression in Graves' orbitopathy: a proposal for standardized evaluation of diplopia

OBJECTIVES: To evaluate the efficacy and side effects of 'swinging eyelid' orbital decompression in patients with Graves' orbitopathy (GO). To calculate the incidence of postoperative new-onset diplopia (NOD) using a newly proposed scoring system for diplopia. METHODS: We reviewed the clinical data on proptosis, visual acuity, and diplopia in 104 consecutive patients (198 orbits) with GO, who underwent orbital decompression. A combined lateral canthal and inferior fornix incision ('swinging eyelid' approach) was used for removal of the medial wall, the orbital floor and, if indicated, the lateral wall. Indications for surgery were disfiguring/congestive GO (DGO) in 79 patients (149 orbits) and compressive optic neuropathy (CON) in 25 patients (49 orbits). Diplopia was scored according to four grades. In both groups, the incidence of new-onset (continuous) diplopia (NOD), deterioration of diplopia (DOD), and improvement of diplopia (IOD) were calculated, using strictly defined criteria. Our data on NOD were compared to those from other series, after recalculation according to our criteria. RESULTS: The mean proptosis reduction was 4.6 mm (range 0-9.5 mm) after three-wall decompression (95 patients, 180 orbits) vs 3.1 mm (range 0-7 mm) after two-wall decompression (nine patients, 18 orbits). The visual acuity improved in 98% of the patients with CON. In patients with DGO, NOD occurred in 14%. In patients with CON, NOD was not observed, but DOD occurred in 41%. Our data compare favourably to the reported incidence of NOD after either transantral or transnasal decompression. CONCLUSIONS: "Swinging eyelid' orbital decompression is efficacious for proptosis reduction as well as for optic nerve decompression. A scoring system for standardized evaluation of diplopia is proposed.     

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.     

Effects of botulinum a toxin injection on the extraocular muscle fiber layers: Comparison between subtenon injection and intramuscular injection

Purpose  To compare the morphological changes following injection of botulinum A toxin to the extraocular muscle fiber layers with those following injection to the subtenon intramuscular system. Methods  Twelve New Zealand white rabbits were divided into two groups. In the first group (six rabbits), four received injections of 10 units of botulinum A toxin into the subtenon space of the superior rectus muscle OD, and the same dose of botulinum A toxin was injected directly into the superior rectus muscle OS. The other two rabbits in the first group were labeled as control animals; 0.1 ml of normal saline was injected into the subtenon space OD, and direct intramuscular injection was performed on the opposite eye. The animals in the first group were killed after 4 weeks to measure the average diameter of the muscle fibers in both the orbital and global layer. In animals of the second group (six rabbits), the same procedures were performed and the animals were killed 12 weeks after treatment. Results  The average diameter of muscle fibers in both the orbital layer and global layer was markedly reduced in all of the botulinum A toxin-injected groups at 4 weeks after treatment compared with the controls. There was no difference in the average diameter of the muscle fibers between the orbital layer of the subtenon-injected group and that of the intramuscular-injected group at 4 weeks after treatment, but the average diameter of the muscle fibers in the global layer was significantly reduced in the intramuscular-injected group compared with the subtenon-injected group at 4 weeks after treatment. At 12 weeks following treatment, there was no difference in the average diameter between the botulinum A toxin-injected group and the control group regardless of where the toxin was injected. Conclusion  Subtenon injection of botulinum A toxin induced similar morphological changes as direct intramuscular injection in the extraocular muscle fiber layers. These results suggest the possibility of clinical applications of subtenon botulinum A toxin injection for the treatment of strabismus. These authors contributed equally to this work.     

Botulinum toxin treatment of acute sixth and third nerve palsy

Thirty-four patients with acute sixth nerve palsy and nine patients with acute third nerve palsy were treated with botulinum toxin injection to the antagonist, nonparalytic horizontal rectus muscle. In a control group of 52 patients with acute sixth nerve palsy not treated with botulinum in the acute stage, only 16 (31 %) recovered spontaneously and did not require surgery. Twenty-two of the 31 surviving patients who could be followed with acute sixth nerve palsy had lateral rectus recovery and surgery was avoided. Four required prisms in their glasses to obtain fusion. Nine patients developed chronic sixth nerve palsy and required surgery. In this group of acute sixth nerve palsy patients, eleven were bilateral. Seven of these eleven developed chronic sixth nerve paralysis, and required strabismus surgery. This suggests the prognosis for recovery following botulinum treatment in cases of acute bilateral sixth nerve palsy is not as good as in the unilateral cases. Botulinum toxin treatment does not appear to be effective in chronic sixth nerve palsy, as judged by results of treatment in one patient known to have a chronic palsy. Nine of nine patients with acute third nerve palsy had medial rectus recovery with fusion horizontally in primary gaze. None have required surgery. Only four of nine showed improvement in vertical rotations. The remaining five patients avoid vertical diplopia by a compensatory chin position. Botulinum toxin treatment of patients with acute sixth and third nerve palsy appears beneficial. However, since some in this group of patients may recover spontaneously, a randomized, double-blind study may be necessary to more definitively determine the effectiveness of this therapy.Dedicated to Dr. G.K. von Noorden on the occasion of his 60th birthday     

Strabismus after retinal detachment surgery: etiology, diagnosis, and treatment

Between 5% and 25% of patients may experience persistent diplopia after surgery for retinal detachment. The complexity of the presentation poses a distinct challenge to both the retinal and the strabismus surgeon. Careful evaluation to determine factors contributing to the strabismus and assessment of fusional capabilities are essential before treatment. A combination of the appropriate surgical approach with nonsurgical adjuncts such as prisms or botulinum toxin is often successful in relieving symptoms.     

Diplopia associated with the cosmetic use of botulinum toxin a for facial rejuvenation

We report three cases in which cosmetic injections of botulinum toxin A around the eye caused diplopia. Diplopia was due to inferior oblique paresis, which was bilateral in two cases. We suggest that consent for periocular botulinum toxin procedures should include a warning about diplopia.     

Strabismus following endoscopic orbital decompression for thyroid eye disease

Endoscopic orbital decompression may be used to treat disfiguring proptosis or sight threatening optic nerve compression in patients with thyroid eye disease. Strabismus is common in thyroid eye disease and frequently follows decompression surgery. We retrospectively reviewed patients undergoing endoscopic decompression for thyroid eye disease, by a single surgeon, from 1994 to 2000. Twenty-three patients (21 female, 2 male) were identified with a mean age of 47.5 years. At presentation, 21 patients had proptosis, 8 optic nerve compression (2 without proptosis) and 11 strabismus (9 complained of diplopia) with a mean BSV score of 24.5 before decompression. Forty orbits were decompressed with a mean decrease in proptosis of 3.3mm. Following decompression, the mean BSV score was 25, and 17 patients had manifest strabismus in primary gaze (3 at near only) of whom 10 had pre-existing strabismus. Five patients had new diplopia (22%). Eleven patients ultimately required strabismus surgery of whom 8 had manifest strabismus before decompression. Following strabismus surgery, the mean BSV score was 37. The final BSV score for those not requiring strabismus surgery was 29. Mean follow-up was 28 months. Endoscopic orbital decompression can effectively treat disfiguring proptosis. Diplopia is a common complication, but pre-existing diplopia may improve.