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Botulinum toxin therapy of strabismus

January 01, 1970

Botulinum toxin therapy of strabismus is a medical technique used sometimes in the management of strabismus, in which botulinum toxin is injected into selected extraocular muscles in order to reduce the misalignment of the eyes. The injection of the toxin to treat strabismus, reported upon in 1981, is considered to be the first ever use of botulinum toxin for therapeutic purposes. Today, the injection of botulinum toxin into the muscles that surround the eyes is one of the available options in the management of strabismus. Other options for strabismus management are vision therapy and occlusion therapy, corrective glasses (or contact lenses) and prism glasses, and strabismus surgery.

Botulinum toxin therapy of strabismus
Specialtyophthalmologist
[edit on Wikidata]

The effects that are due only to the toxin itself (including the side effects) generally wear off within 3 to 4 months. In contrast, improvements in alignment may be long-lasting, particularly in two circumstances. First, if the "antagonist" muscle (the muscle pulling in the opposite direction) is active, the injected muscle will be stretched, and may permanently lengthen by adding tissue during the period of toxin paresis.[citation needed] Second, if binocular vision has been achieved and stabilized, alignment may "lock in". There are indications that botulinum toxin therapy is as successful as strabismus surgery for patients with binocular vision and that it is less successful than surgery for those who have no binocular vision.[1]

Principle edit

Botulinum toxin is the most acutely lethal toxin that is known. It is produced by the bacterium clostridium botulinum. It acts inside nerve terminals by decreasing the release of acetylcholine, blocking neuromuscular transmission and thereby causing flaccid muscular paralysis. As a result, the muscle is weakened for about 3 to 4 months.

For treating strabismus, the toxin is used in much diluted form, and the injection is targeted to reach specific muscles that move the eye, thereby temporarily weakening the selected muscles.

Technique edit

Injection edit

After local or general anaesthesia has been applied, the botulinum toxin is injected directly into the selected eye muscles using a specially designed needle electrode that is connected to an electromyography (EMG) apparatus as well as to a syringe containing the botulinum toxin solution.[2]

When under local anaesthesia, the patient is asked to move the eyes just before the toxin is injected. This results in an EMG signal which provides instant feedback on the correct placement of the needle. If the patient is a young child, general anaesthesia is always used.[2]

The duration of the intervention is one to two minutes if the person performing the procedure has sufficient experience.[2]

Dosage edit

The dosage to be used cannot be determined with precision, as no reliable relation between dose and effect could be established so far.[1] The toxicity of botulinum toxin varies from one lot to the next; furthermore, the body may show an immunoreaction by which the efficacy of subsequent treatments is reduced.[2]

Clinical use edit

Botulinum toxin is considered as an alternative to surgery in certain clinical situations. A study performed in the 1980s found outcomes of surgery to be "more predictable and longer lasting" than those of botulinum toxin therapy.[3] As stated in a review article of 2007, its use for strabismus "varies enormously in different cities and countries for no apparent reason."[4]

In a small-scale study, adults whose reading difficulties due to convergence insufficiency had been unsuccessfully addressed by convergence exercises, base-in prism glasses or strabismus surgery showed improved reading after botulinum toxin therapy, maintaining improved reading remaining also after six months.[5]

Use as primary therapy edit

Botulinum toxin is considered a useful alternative to surgery in particular cases, for example for persons unfit for general anaesthesia, in evolving or unstable clinical conditions, after unsuccessful surgery, or to provide short-term relief from diplopia.[4]

For patients who have had healthy vision heretofore until a small, horizontal deviation set in suddenly, the injection of botulinum toxin may allow them to maintain the binocular vision skills that had been acquired earlier.[6]

Some consider botulinum injections to be a treatment option for children with small- to moderate-angle infantile esotropia.[7][8] Studies have provided indications that performing injections into both medial rectus muscles may be more effective than an injection into one medial rectus muscle alone.[2]

Botulinum toxin therapy has been reported to be similarly successful as strabismus surgery for patients with binocular vision and less successful than surgery for those who have no binocular vision.[9] One study found that botulinum toxin therapy had similar long-term success rates for treating infantile esotropia with botulinum toxin A before the age of 12 months as would have been expected from strabismus surgery.[10] Another study reported similar long-term success rates for infantile esotropia treated before 24 months of age by either strabismus surgery or botulinum toxin treatment.[11]

Intra- and postoperational use edit

Botulinum toxin has also been used postoperatively for improving the alignment in patients with over- or undercorrection after strabismus surgery, leading to rapid elimination of postoperative diplopia but possibly requiring repeated injections or reoperation later on.[12] It is considered particularly useful for patients who have the potential for binocular vision; success rates are higher for treating postoperative esotropia than for treating postoperative exotropia.[6]

It has also been employed in combination with strabismus surgery in cases in which there is a large horizontal eye deviation and eye muscle surgery on both eyes (binocular surgery) is not an option for other reasons.[13]

Side effects edit

The most common side effects are droopy eyelids (ptosis) and over- or undercorrections;[4] a further common side effects are diplopia and inadvertent vertical deviation (hypo- or hypertropia).[3] The side effects typically resolve in 3–4 months.[1]

Vision-threatening complications are rare, and the intervention is generally considered safe, also when performed repeatedly.[1]

Bupivacaine edit

It is also under investigation whether the injection of bupivacaine into extraocular muscles is of possible therapeutic use for treating some forms of strabismus, be it alone or in combination with botulinum toxin.

Bupivacaine is a local anaesthetic known to cause considerable myotoxicity and neurotoxicity. Its injection into muscle tissue leads to a dramatic degeneration of muscle fibres accompanied by a moderate inflammatory response. It subsequently leads to a thickening and strengthening of the muscle. The thickening of bupivacaine-injected extraocular muscle has been demonstrated by means of magnetic resonance imaging[14] and by means of ultrasonography.[15]

Bupivacaine injection is therefore being investigated as a further possibility of treating strabismus. In some interventions bupivacaine has been used alone.[16][17] In others, a botulinum toxin injection into an extraocular muscle is accompanied by a bupivacaine injection into the antagonist muscle.[15][18]

History edit

Alan B. Scott first injected botulinum toxin into extraocular muscles since the early 1970s[2] and published his results 1981,[19] giving rise to a wide scope of clinical research on the use of the toxin.

The effect of bupivaine injection on extraocular muscles was first known as causing postsurgical strabismus as a complication of cataract surgery due to the myotoxicity of the local anaesthetic drug bupivaine when inadvertently injected into an extraocular muscle.

See also: Botulinum toxin § Blepharospasm and strabismus

References edit

  1. ^ a b c d Rowe, Fiona J.; Noonan, Carmel P. (2 March 2017). "Botulinum toxin for the treatment of strabismus". The Cochrane Database of Systematic Reviews. 2017 (3): CD006499. doi:10.1002/14651858.CD006499.pub4. ISSN 1469-493X. PMC 6464099. PMID 28253424.
  2. ^ a b c d e f (PDF). Archived from the original (PDF) on 2014-04-13. Retrieved 2014-04-12., pages 559–565. In: Gunter K. von Noorden, Emilio C. Campos: Binocular Vision and Ocular Motility: Theory and Management of Strabismus 2014-04-13 at the Wayback Machine, Sixth Edition. Ophthalmology Books & Manuals (Cyber Sight), Orbis International
  3. ^ a b Flanders M; et al. (June 1987). "Injection of type A botulinum toxin into extraocular muscles for correction of strabismus". Can. J. Ophthalmol. 22 (4): 212–217. PMID 3607594.
  4. ^ a b c Kowal L, Wong E, Yahalom C (Dec 15, 2007). "Botulinum toxin in the treatment of strabismus. A review of its use and effects". Disabil Rehabil. 29 (23): 1823–1831. doi:10.1080/09638280701568189. PMID 18033607. S2CID 19053824.
  5. ^ Peiter Saunte, Jon; Holmes, Jonathan M. (2014). "Sustained improvement of reading symptoms following botulinum toxin A injection for convergence insufficiency". Strabismus. 22 (3): 95–99. doi:10.3109/09273972.2014.907815. PMC 4324975. PMID 24786379.
  6. ^ a b Ripley L, Rowe FJ (July–September 2007). "Use of botulinum toxin in small-angle heterotropia and decompensating heterophoria: a review of the literature". Strabismus. 15 (3): 165–171. doi:10.1080/09273970701506094. PMID 17763254. S2CID 21369595.
  7. ^ Thouvenin D, Lesage-Beaudon C, Arné JL (January 2008). "(translated from French) Botulinum injection in infantile strabismus. Results and incidence on secondary surgery in a long-term survey of 74 cases treated before 36 months of age". J Fr Ophtalmol. 31 (1): 42–50. doi:10.1016/S0181-5512(08)70329-2. PMID 18401298.
  8. ^ de Alba Campomanes AG, Binenbaum G, Campomanes Eguiarte G (April 2010). "Comparison of botulinum toxin with surgery as primary treatment for infantile esotropia". J AAPOS. 14 (2): 111–116. doi:10.1016/j.jaapos.2009.12.162. PMID 20451851.
  9. ^ Rowe FJ, Noonan CP (2017). "Botulinum toxin for the treatment of strabismus". Cochrane Database Syst Rev. 2017 (3): CD006499. doi:10.1002/14651858.CD006499.pub4. PMC 6464099. PMID 28253424.
  10. ^ McNeer KW, Tucker MG, Guerry CH, Spencer RF (2003). "Incidence of stereopsis after treatment of infantile esotropia with botulinum toxin A". Journal of Pediatric Ophthalmology and Strabismus. 40 (5): 288–92. doi:10.3928/0191-3913-20030901-10. PMID 14560837.
  11. ^ Gursoy, Huseyin; Basmak, Hikmet; Sahin, Afsun; Yildirim, Nilgun; Aydin, Yasemin; Colak, Ertugrul (2012). "Long-term follow-up of bilateral botulinum toxin injections versus bilateral recessions of the medial rectus muscles for treatment of infantile esotropia". Journal of American Association for Pediatric Ophthalmology and Strabismus. 16 (3): 269–273. doi:10.1016/j.jaapos.2012.01.010. ISSN 1091-8531. PMID 22681945.
  12. ^ Wutthiphan S. (2008). "Botulinum toxin A in surgically overcorrected and undercorrected strabismus". J. Med. Assoc. Thai. 91 (Suppl. 1): 86–91. PMID 18672599.
  13. ^ Nilza Minguini; et al. (March 2012). "Surgery with intraoperative botulinum toxin-A injection for the treatment of large-angle horizontal strabismus: a pilot study". Clinics (Sao Paulo). 67 (3): 279–282. doi:10.6061/clinics/2012(03)13. PMC 3297039. PMID 22473411.
  14. ^ Creig S Hoyt (February 2007). "A problem! Now a solution?". British Journal of Ophthalmology. 91 (2): 127–128. doi:10.1136/bjo.2006.111096. PMC 1857604. PMID 17244653.
  15. ^ a b Hopker, LM; Zaupa, PF; Lima Filho, AA; Cronemberger, MF; Tabuse, MK; Nakanami, CR; Allemann, N.; Mendonça, TS (March–April 2012). "Bupivacaine and botulinum toxin to treat comitant strabismus". Arquivos Brasileiros de Oftalmologia. 75 (2): 111–115. doi:10.1590/s0004-27492012000200008. PMID 22760802.
  16. ^ Scott, AB; Miller, JM; Shieh, KR (April 2009). "Bupivacaine injection of the lateral rectus muscle to treat esotropia". J AAPOS. 13 (2): 119–122. doi:10.1016/j.jaapos.2008.10.016. PMID 19393509.
  17. ^ Miller, JM; Scott, AB; Danh, KK; Strasser, D; Sane, M (December 2013). "Bupivacaine injection remodels extraocular muscles and corrects comitant strabismus". Ophthalmology. 120 (12): 2733–2740. doi:10.1016/j.ophtha.2013.06.003. PMID 23916485.
  18. ^ Scott, AB; Miller, JM; Shieh, KR (December 2009). "Treating strabismus by injecting the agonist muscle with bupivacaine and the antagonist with botulinum toxin". Transactions of the American Ophthalmological Society. 107: 104–109. PMC 2814569. PMID 20126486.
  19. ^ Scott AB (1981). "Botulinum toxin injection of eye muscles to correct strabismus". Trans Am Ophthalmol Soc. 79 (79): 734–770. PMC 1312202. PMID 7043872.

Further reading edit

  • (Gabrielle Weiner interviewing Alejandra de Alba Campomanes, David G. Hunter, and Gregg T. Lueder), Clinical Update: Pediatrics, EyeNet Magazine, August 2012 (American Academy of Ophthalmology)

January 01, 1970
botulinum, toxin, therapy, strabismus, medical, technique, used, sometimes, management, strabismus, which, botulinum, toxin, injected, into, selected, extraocular, muscles, order, reduce, misalignment, eyes, injection, toxin, treat, strabismus, reported, upon,. Botulinum toxin therapy of strabismus is a medical technique used sometimes in the management of strabismus in which botulinum toxin is injected into selected extraocular muscles in order to reduce the misalignment of the eyes The injection of the toxin to treat strabismus reported upon in 1981 is considered to be the first ever use of botulinum toxin for therapeutic purposes Today the injection of botulinum toxin into the muscles that surround the eyes is one of the available options in the management of strabismus Other options for strabismus management are vision therapy and occlusion therapy corrective glasses or contact lenses and prism glasses and strabismus surgery Botulinum toxin therapy of strabismusSpecialtyophthalmologist edit on Wikidata The effects that are due only to the toxin itself including the side effects generally wear off within 3 to 4 months In contrast improvements in alignment may be long lasting particularly in two circumstances First if the antagonist muscle the muscle pulling in the opposite direction is active the injected muscle will be stretched and may permanently lengthen by adding tissue during the period of toxin paresis citation needed Second if binocular vision has been achieved and stabilized alignment may lock in There are indications that botulinum toxin therapy is as successful as strabismus surgery for patients with binocular vision and that it is less successful than surgery for those who have no binocular vision 1 Contents 1 Principle 2 Technique 2 1 Injection 2 2 Dosage 3 Clinical use 3 1 Use as primary therapy 3 2 Intra and postoperational use 4 Side effects 5 Bupivacaine 6 History 7 References 8 Further readingPrinciple editBotulinum toxin is the most acutely lethal toxin that is known It is produced by the bacterium clostridium botulinum It acts inside nerve terminals by decreasing the release of acetylcholine blocking neuromuscular transmission and thereby causing flaccid muscular paralysis As a result the muscle is weakened for about 3 to 4 months For treating strabismus the toxin is used in much diluted form and the injection is targeted to reach specific muscles that move the eye thereby temporarily weakening the selected muscles Technique editInjection edit After local or general anaesthesia has been applied the botulinum toxin is injected directly into the selected eye muscles using a specially designed needle electrode that is connected to an electromyography EMG apparatus as well as to a syringe containing the botulinum toxin solution 2 When under local anaesthesia the patient is asked to move the eyes just before the toxin is injected This results in an EMG signal which provides instant feedback on the correct placement of the needle If the patient is a young child general anaesthesia is always used 2 The duration of the intervention is one to two minutes if the person performing the procedure has sufficient experience 2 Dosage edit The dosage to be used cannot be determined with precision as no reliable relation between dose and effect could be established so far 1 The toxicity of botulinum toxin varies from one lot to the next furthermore the body may show an immunoreaction by which the efficacy of subsequent treatments is reduced 2 Clinical use editBotulinum toxin is considered as an alternative to surgery in certain clinical situations A study performed in the 1980s found outcomes of surgery to be more predictable and longer lasting than those of botulinum toxin therapy 3 As stated in a review article of 2007 its use for strabismus varies enormously in different cities and countries for no apparent reason 4 In a small scale study adults whose reading difficulties due to convergence insufficiency had been unsuccessfully addressed by convergence exercises base in prism glasses or strabismus surgery showed improved reading after botulinum toxin therapy maintaining improved reading remaining also after six months 5 Use as primary therapy edit Botulinum toxin is considered a useful alternative to surgery in particular cases for example for persons unfit for general anaesthesia in evolving or unstable clinical conditions after unsuccessful surgery or to provide short term relief from diplopia 4 For patients who have had healthy vision heretofore until a small horizontal deviation set in suddenly the injection of botulinum toxin may allow them to maintain the binocular vision skills that had been acquired earlier 6 Some consider botulinum injections to be a treatment option for children with small to moderate angle infantile esotropia 7 8 Studies have provided indications that performing injections into both medial rectus muscles may be more effective than an injection into one medial rectus muscle alone 2 Botulinum toxin therapy has been reported to be similarly successful as strabismus surgery for patients with binocular vision and less successful than surgery for those who have no binocular vision 9 One study found that botulinum toxin therapy had similar long term success rates for treating infantile esotropia with botulinum toxin A before the age of 12 months as would have been expected from strabismus surgery 10 Another study reported similar long term success rates for infantile esotropia treated before 24 months of age by either strabismus surgery or botulinum toxin treatment 11 Intra and postoperational use edit Botulinum toxin has also been used postoperatively for improving the alignment in patients with over or undercorrection after strabismus surgery leading to rapid elimination of postoperative diplopia but possibly requiring repeated injections or reoperation later on 12 It is considered particularly useful for patients who have the potential for binocular vision success rates are higher for treating postoperative esotropia than for treating postoperative exotropia 6 It has also been employed in combination with strabismus surgery in cases in which there is a large horizontal eye deviation and eye muscle surgery on both eyes binocular surgery is not an option for other reasons 13 Side effects editThe most common side effects are droopy eyelids ptosis and over or undercorrections 4 a further common side effects are diplopia and inadvertent vertical deviation hypo or hypertropia 3 The side effects typically resolve in 3 4 months 1 Vision threatening complications are rare and the intervention is generally considered safe also when performed repeatedly 1 Bupivacaine editIt is also under investigation whether the injection of bupivacaine into extraocular muscles is of possible therapeutic use for treating some forms of strabismus be it alone or in combination with botulinum toxin Bupivacaine is a local anaesthetic known to cause considerable myotoxicity and neurotoxicity Its injection into muscle tissue leads to a dramatic degeneration of muscle fibres accompanied by a moderate inflammatory response It subsequently leads to a thickening and strengthening of the muscle The thickening of bupivacaine injected extraocular muscle has been demonstrated by means of magnetic resonance imaging 14 and by means of ultrasonography 15 Bupivacaine injection is therefore being investigated as a further possibility of treating strabismus In some interventions bupivacaine has been used alone 16 17 In others a botulinum toxin injection into an extraocular muscle is accompanied by a bupivacaine injection into the antagonist muscle 15 18 History editAlan B Scott first injected botulinum toxin into extraocular muscles since the early 1970s 2 and published his results 1981 19 giving rise to a wide scope of clinical research on the use of the toxin The effect of bupivaine injection on extraocular muscles was first known as causing postsurgical strabismus as a complication of cataract surgery due to the myotoxicity of the local anaesthetic drug bupivaine when inadvertently injected into an extraocular muscle See also Botulinum toxin Blepharospasm and strabismusReferences edit a b c d Rowe Fiona J Noonan Carmel P 2 March 2017 Botulinum toxin for the treatment of strabismus The Cochrane Database of Systematic Reviews 2017 3 CD006499 doi 10 1002 14651858 CD006499 pub4 ISSN 1469 493X PMC 6464099 PMID 28253424 a b c d e f Chapter 25 Chemodenervation of Extraocular Muscles Botulinum Toxin PDF Archived from the original PDF on 2014 04 13 Retrieved 2014 04 12 pages 559 565 In Gunter K von Noorden Emilio C Campos Binocular Vision and Ocular Motility Theory and Management of Strabismus Archived 2014 04 13 at the Wayback Machine Sixth Edition Ophthalmology Books amp Manuals Cyber Sight Orbis International a b Flanders M et al June 1987 Injection of type A botulinum toxin into extraocular muscles for correction of strabismus Can J Ophthalmol 22 4 212 217 PMID 3607594 a b c Kowal L Wong E Yahalom C Dec 15 2007 Botulinum toxin in the treatment of strabismus A review of its use and effects Disabil Rehabil 29 23 1823 1831 doi 10 1080 09638280701568189 PMID 18033607 S2CID 19053824 Peiter Saunte Jon Holmes Jonathan M 2014 Sustained improvement of reading symptoms following botulinum toxin A injection for convergence insufficiency Strabismus 22 3 95 99 doi 10 3109 09273972 2014 907815 PMC 4324975 PMID 24786379 a b Ripley L Rowe FJ July September 2007 Use of botulinum toxin in small angle heterotropia and decompensating heterophoria a review of the literature Strabismus 15 3 165 171 doi 10 1080 09273970701506094 PMID 17763254 S2CID 21369595 Thouvenin D Lesage Beaudon C Arne JL January 2008 translated from French Botulinum injection in infantile strabismus Results and incidence on secondary surgery in a long term survey of 74 cases treated before 36 months of age J Fr Ophtalmol 31 1 42 50 doi 10 1016 S0181 5512 08 70329 2 PMID 18401298 de Alba Campomanes AG Binenbaum G Campomanes Eguiarte G April 2010 Comparison of botulinum toxin with surgery as primary treatment for infantile esotropia J AAPOS 14 2 111 116 doi 10 1016 j jaapos 2009 12 162 PMID 20451851 Rowe FJ Noonan CP 2017 Botulinum toxin for the treatment of strabismus Cochrane Database Syst Rev 2017 3 CD006499 doi 10 1002 14651858 CD006499 pub4 PMC 6464099 PMID 28253424 McNeer KW Tucker MG Guerry CH Spencer RF 2003 Incidence of stereopsis after treatment of infantile esotropia with botulinum toxin A Journal of Pediatric Ophthalmology and Strabismus 40 5 288 92 doi 10 3928 0191 3913 20030901 10 PMID 14560837 Gursoy Huseyin Basmak Hikmet Sahin Afsun Yildirim Nilgun Aydin Yasemin Colak Ertugrul 2012 Long term follow up of bilateral botulinum toxin injections versus bilateral recessions of the medial rectus muscles for treatment of infantile esotropia Journal of American Association for Pediatric Ophthalmology and Strabismus 16 3 269 273 doi 10 1016 j jaapos 2012 01 010 ISSN 1091 8531 PMID 22681945 Wutthiphan S 2008 Botulinum toxin A in surgically overcorrected and undercorrected strabismus J Med Assoc Thai 91 Suppl 1 86 91 PMID 18672599 Nilza Minguini et al March 2012 Surgery with intraoperative botulinum toxin A injection for the treatment of large angle horizontal strabismus a pilot study Clinics Sao Paulo 67 3 279 282 doi 10 6061 clinics 2012 03 13 PMC 3297039 PMID 22473411 Creig S Hoyt February 2007 A problem Now a solution British Journal of Ophthalmology 91 2 127 128 doi 10 1136 bjo 2006 111096 PMC 1857604 PMID 17244653 a b Hopker LM Zaupa PF Lima Filho AA Cronemberger MF Tabuse MK Nakanami CR Allemann N Mendonca TS March April 2012 Bupivacaine and botulinum toxin to treat comitant strabismus Arquivos Brasileiros de Oftalmologia 75 2 111 115 doi 10 1590 s0004 27492012000200008 PMID 22760802 Scott AB Miller JM Shieh KR April 2009 Bupivacaine injection of the lateral rectus muscle to treat esotropia J AAPOS 13 2 119 122 doi 10 1016 j jaapos 2008 10 016 PMID 19393509 Miller JM Scott AB Danh KK Strasser D Sane M December 2013 Bupivacaine injection remodels extraocular muscles and corrects comitant strabismus Ophthalmology 120 12 2733 2740 doi 10 1016 j ophtha 2013 06 003 PMID 23916485 Scott AB Miller JM Shieh KR December 2009 Treating strabismus by injecting the agonist muscle with bupivacaine and the antagonist with botulinum toxin Transactions of the American Ophthalmological Society 107 104 109 PMC 2814569 PMID 20126486 Scott AB 1981 Botulinum toxin injection of eye muscles to correct strabismus Trans Am Ophthalmol Soc 79 79 734 770 PMC 1312202 PMID 7043872 Further reading editReassessing Botulinum Toxin for Childhood Strabismus Gabrielle Weiner interviewing Alejandra de Alba Campomanes David G Hunter and Gregg T Lueder Clinical Update Pediatrics EyeNet Magazine August 2012 American Academy of Ophthalmology Retrieved from https en wikipedia org w index php title Botulinum toxin therapy of strabismus amp oldid 1139401982, wikipedia, wiki, book, books, library,

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