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Cheung CSY, Wan MJ, Zurakowski D, Kodsi S, Ekdawi NS, Russell HC, Shetty S, Dumitrescu AV, Dagi LR, Shah AS, Hunter DG. A Comparison of Chemodnervation to Incisional Surgery for Acute, Acquired, Comitant Esotropia: An International Study. Am J Ophthalmol 2024; 263:160-167. [PMID: 38447598 DOI: 10.1016/j.ajo.2024.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE To compare the efficacy of botulinum toxin injections to strabismus surgery in children with acute, acquired, comitant esotropia (ACE), and to investigate factors predicting success. DESIGN International, multi-center nonrandomized comparative study METHODS: Setting: Cloud-based survey. STUDY POPULATION Children aged 2 to 17 years who underwent a single surgical intervention for ACE. INTERVENTIONS Botulinum toxin injection ("chemodenervation" group) or strabismus surgery ("surgery" group). MAIN OUTCOME MEASURES Primary measure: success rate at 6 months in propensity-matched cohort, defined as total horizontal deviation of 10 prism diopters or less with evidence of binocular single vision. Secondary measure: Risk factors for poor outcomes in the full cohort. RESULTS Surgeons from 19 centers contributed. There were 74 patients in the chemodenervation group and 97 patients in the surgery group. In the propensity-matched data (n = 98), success rate was not significantly different at 6 months (70.2% vs 79.6%; P = .2) and 12 months (62.9% vs 77.8%; P = .2), but was significantly lower in the chemodenervation group at 24 months (52% vs 86.4%; P = .015). Irrespective of treatment modality, treatment delay was associated with lower success rates at 6 months, with median time from onset to intervention 4.5 months (interquartile range (IQR): 2.1, 6.7) in the success group and 7.7 months (IQR: 5.6, 10.1) in the failure group (P < .001). CONCLUSIONS In children with ACE, success rate after chemodenervation was similar to that of surgery for up to 12 months but lower at 24 months. Those with prompt intervention and no amblyopia had the most favorable outcomes, regardless of treatment modality.
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Affiliation(s)
- Crystal S Y Cheung
- From the Department of Ophthalmology (C.C, L.D, A.S, D.H), Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA; Department of Ophthalmology and Vision Science (C.C, M.W), University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael J Wan
- Department of Ophthalmology and Vision Science (C.C, M.W), University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Zurakowski
- Departments of Anesthesiology and Surgery, Boston Children's Hospital (D.Z), Harvard Medical School, Boston, Massachusetts, USA
| | - Sylvia Kodsi
- Department of Ophthalmology (S.K), Northwell Health, Great Neck, New York, USA
| | - Noha S Ekdawi
- Department of Ophthalmology (N.E), Wheaton Eye Clinic, Wheaton, Illinois, USA
| | - Heather C Russell
- Faculty of Health Sciences & Medicine, Bond University and Department of Ophthalmology (H.R), Gold Coast University Hospital, Gold Coast, Australia
| | - Shashikant Shetty
- Paediatric Ophthalmology (S.S), Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Alina V Dumitrescu
- Department of Ophthalmology (A.D), University of Iowa, Iowa City, Iowa, USA
| | - Linda R Dagi
- From the Department of Ophthalmology (C.C, L.D, A.S, D.H), Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ankoor S Shah
- From the Department of Ophthalmology (C.C, L.D, A.S, D.H), Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - David G Hunter
- From the Department of Ophthalmology (C.C, L.D, A.S, D.H), Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA.
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Zedan R, Badr R, Khazbak L, Salah M. Pharmacological treatment of strabismus in children. DELTA JOURNAL OF OPHTHALMOLOGY 2023. [DOI: 10.4103/djo.djo_46_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
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Kassem RR, Badr RAA, Al Zarea BKA, Almasaud JS, Alshomer FM, El-Sada MA, Zedan RH. Botulinum Toxin Injection in Horizontal Rectus Muscles Without Electromyography Using an Open Sky Versus a Closed Sky Technique. J Pediatr Ophthalmol Strabismus 2022; 59:388-395. [PMID: 35275777 DOI: 10.3928/01913913-20220210-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To ascertain whether electromyographic control when injecting botulinum toxin in the horizontal rectus muscles is necessary, and to compare the open sky and closed sky injection techniques that are used without electromyographic control. METHODS The records of 135 patients with horizontal strabismus who received botulinum toxin injections were reviewed retrospectively. Sevoflurane or propofol anesthesia was used in children, and topical benoxinate hydrochloride was used in adults. Patients received a bilateral injection of 2.5 to 15 IU of botulinum toxin, without electromyographic control, into the medial or lateral rectus muscles to correct esotropia or exotropia, respectively. An open sky technique was used in 31 patients, and a closed sky technique was used in 104 patients. Postoperative alignment within 10 prism diopters (PD) of orthotropia was considered a successful outcome. RESULTS A successful outcome at 6 months of follow-up was achieved in 47% of all patients: 59% of patients in the open sky group and 44% of patients in the closed sky group (P = .151). Botulinum toxin injection corrected a mean of 14 ± 9.705 PD in patients in the open sky group and 31 ± 20.589 PD in patients in the closed sky group to obtain mean residual angles of 21 ± 16.692 and 13 ± 11.901 PD, respectively. CONCLUSIONS The results obtained without electromyographic assistance were not remarkably different from the studies using electromyographic control. Moreover, because the results of the open sky technique were not significantly superior to the closed sky technique, the latter was favored to shorten the operative time and postoperative convalescence, and to reduce the risk of postoperative adhesions and scarring, which made re-operations difficult. [J Pediatr Ophthalmol Strabismus. 2022;59(6):388-395.].
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Binenbaum G, Chang MY, Heidary G, Morrison DG, Trivedi RH, Galvin JA, Pineles SL. Botulinum Toxin Injection for the Treatment of Strabismus: A Report by the American Academy of Ophthalmology. Ophthalmology 2021; 128:1766-1776. [PMID: 34176652 DOI: 10.1016/j.ophtha.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To review the available evidence comparing the effectiveness of extraocular muscle botulinum toxin type A (BTXA) injection with eye muscle surgery for restoring ocular alignment in children and adults with nonparalytic, nonrestrictive horizontal strabismus. METHODS Literature searches in the PubMed Cochrane Library, and clinical trial databases with no date restrictions, but limited to articles published in English, were conducted last on January 10, 2021. The searches yielded 515 citations, 40 of which were reviewed in full text by the first author. Fourteen articles met the criteria for inclusion (randomized or nonrandomized comparative studies, or case series with a minimum 50 patients; evaluating extraocular muscle BTXA injection for initial or repeat treatment of horizontal, nonparalytic, nonrestrictive strabismus; with at least 6 months of follow-up) and were graded by a methodologist. RESULTS The 14 included studies consisted of 2 randomized clinical trials, 3 nonrandomized comparative studies, and 9 case series. All 5 comparative studies were graded level II evidence, and the 9 case series were graded level III evidence. Successful motor outcomes after BTXA injection were relatively consistent across 4 of the 5 comparative studies at 60%, when adjustment was made for differential selection bias in 1 of the studies. In the 4 studies, successful motor outcomes after surgery ranged from 66% to 77% with a mean follow-up of 23 to 75 months, and the outcomes were not significantly different from those after BTXA injection. In the fifth level II study, success was significantly higher with BTXA injection than with surgery (94% vs. 72%). The level III BTXA case series demonstrated higher motor success rates of 87% to 89% when children were treated in 2 muscles at a time; rates were lower in adults treated with single-muscle BTXA injection. CONCLUSIONS Extraocular muscle injection of BTXA achieves a high rate of successful motor alignment, comparable with that achieved after eye muscle surgery for nonparalytic, nonrestrictive horizontal strabismus. Good alignment may require multiple BTXA injections, and it is not yet clear whether sensory outcomes are equivalent for BTXA injections versus eye muscle surgery in young children.
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Affiliation(s)
- Gil Binenbaum
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melinda Y Chang
- Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Gena Heidary
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David G Morrison
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rupal H Trivedi
- Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina
| | - Jennifer A Galvin
- Eye Physicians and Surgeons PC, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut
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Alshamlan FT, Al Abdulhadi HA, Alwalmany MM, Alotaibi KS. The Efficacy of Dose Increments of Botulinum Toxin A in the Treatment of Childhood Esotropia. Clin Ophthalmol 2021; 15:113-120. [PMID: 33469257 PMCID: PMC7811462 DOI: 10.2147/opth.s294396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/30/2020] [Indexed: 11/23/2022] Open
Abstract
Background Botulinum toxin is known to have a powerful chemodenervation effect, and it is a well-established alternative to incisional surgery for strabismus. This study aims to investigate the efficacy of dose increments of botulinum toxin A (BTA) for the treatment of specific ranges of angle deviation. Methods This was a prospective study that included patients presenting with esotropia to Dhahran Eye Specialist Hospital between 2016 and 2020, who were managed by a single surgeon. Botulinum toxin was given in different dosages (2.5, 5, 7.5, 10 international units (IU)) according to the size of deviation (11–19, 20–29, 30–39, and ≥40 prism diopters (PD)), respectively. A successful outcome was defined as deviation ≤10 PD in the last visit (a minimum of 6 months) following a single injection. Results A total of 56 patients with esotropia were included. The mean pre-treatment angle of deviation was 38.6 ± 2.5 PD. BTA injection in a dose of 2.5 IU for the 11–19 PD angle of deviation showed the highest rate of successful outcomes (75%). According to the type of esotropia, partially accommodative esotropia showed the best response to the use of dose increments (59%). The incidence of ptosis post-BTA injection was the least (37.5%) with the smallest dose (2.5 IU). Conclusion BTA usage in dose increments is safe, efficient, and might be more cost-effective with less incidence of BTA associated complications. Different esotropia diagnoses have different clinical responses. However, larger studies are necessary to better predict the outcome of using dose increments.
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Affiliation(s)
- Fatemah T Alshamlan
- Pediatric Ophthalmology and Strabismus Department, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
| | - Halla A Al Abdulhadi
- Pediatric Ophthalmology and Strabismus Department, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
| | - Mofi M Alwalmany
- Pediatric Ophthalmology and Strabismus Department, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
| | - Khalid S Alotaibi
- Pediatric Ophthalmology and Strabismus Department, Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
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