Golden Indications and an Overview on the Use of Botulinum Toxin in Strabismus

Seyhan B. Özkan

doi:10.4274/tjo.galenos.2023.37806

Golden Indications and an Overview on the Use of Botulinum Toxin in Strabismus

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Invited Paper

Golden Indications and an Overview on the Use of Botulinum Toxin in Strabismus

Turk J Ophthalmol 2023;53(6):377-385 DOI: 10.4274/tjo.galenos.2023.37806

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Abstract

Botulinum toxin A (BTXA) is considered a pharmacological agent that may provide an alternative treatment to surgery in strabismus. It can be used as both a diagnostic and therapeutic agent in various concomitant, paralytic, and restrictive disorders. The major advantage of BTXA treatment is that it is non-invasive and does not impact the patient’s chance for future surgery in case of an unfavorable response. In some selected disorders, BTXA has become the primary choice of treatment, whereas surgery is found to be more effective in others. Accumulated knowledge and experience have demonstrated that BTXA is more than merely an alternative treatment and has additional specific indications such as in unstable deviations and as an adjunct to surgery. Patients with recurrent deviations despite multiple surgeries are also good candidates for BTXA treatment. Although the major expectation is to obtain a permanent result, BTXA can also be used as a maintenance treatment. This paper mainly focuses on the current indications for the use of BTXA in strabismology, with special emphasis on ideal first-choice applications referred to as “golden indications,” within the scope of the author’s own experience with the use of BTXA over 30 years.

Keywords: Botulinum toxin, strabismus, strabismus surgery, paralytic strabismus, pharmacological treatment of strabismus

Introduction

Botulinum toxin A (BTXA) has been used for the pharmacological treatment of strabismus for over three decades. In most of the strabismus literature it is mainly regarded as an alternative to surgery depending on the choice of the strabismologist. However, accumulated knowledge and experience have demonstrated that BTXA is not only an alternative therapy but has some additional indications where surgery is not a good option.^, Despite a dearth of randomized controlled trials, BTXA seems to have comparable results with surgery in selected motility problems.^,^, In this paper, the best indications for the use of BTXA, hereafter referred to as “golden indications,” will be highlighted with literature results and the author’s own experience with the use of BTXA in strabismus over 30 years.

Conclusion

In summary, there are five indication categories of BTXA treatment in strabismus:

• Alternative to surgery and prisms in selected concomitant, restrictive, and paralytic deviations,

• A necessary additional agent in acute deviations where surgery is not an alternative,

• Good choice in surgical failures,

• Good choice to increase surgical success,

• Only choice if surgery is not an option for any reason.

In conclusion, BTXA treatment has become the primary option in certain strabismus problems. Strabismologists are recommended to be familiar with BTXA treatment, as it has gained its own non-surgical indications and has an adjunctive role in the management of challenging motility problems rather than being only an alternative treatment based on physician preference.

Figure 1. (A) A child with history of preterm birth had sixth nerve palsy in the right eye related to intracranial hemorrhage at 5 months of age. (B) The child was not treated and returned at 7 years of age with a very large right esotropia and severe limitation of abduction. There was severe antagonist contracture and orbital fibrosis. (C) The medial rectus muscle was recessed 14 mm from the insertion and botulinum toxin A was injected in combination with modified Nishida transposition in the same session. Forced duction test was still positive on abduction at the end of operation. (D) On postoperative day 13, there was severe overcorrection with limitation of adduction. The effect resembled that of traction sutures. (E) At postoperative 16 months, the result was stable with limited abduction and moderate limitation of adduction

Figure 2. The mechanism of effect in lost muscle and adherence syndrome. When an extraocular muscle is lost, contracture of the antagonist develops and pulls the globe. Botulinum toxin A injection into the antagonist extraocular muscle in the acute phase prevents antagonist contracture and keeps the eye in primary position. Thus, any possible attachments around the extraocular muscle attach to the globe more anteriorly (at point “a” instead of “b”). Similarly, in adherence syndrome the inflammatory adipose tissue reaction pulls the globe and limits ocular motility. Botulinum toxin A injection during the acute phase keeps the eye in primary position and allows the attachments to develop at a more posterior point (“d” instead of “c”), thereby reducing limitation of ocular motility
*BTXA: Botulinum toxin A*

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