Surgery and botulinum toxin in congenital esotropia.
BACKGROUND
In a previous study we investigated the advantages and drawbacks of early and delayed injection of botulinum toxin as primary treatment of infantile esotropia with nystagmus in abduction (IENA). We carried out a further study to investigate the role and efficacy of surgery in this condition and to determine the possible effect of previous injection of both medial recti with botulinum toxin in patients requiring a final horizontal surgical correction.


METHODS
Review of the records of 44 patients (24 girls and 20 boys) with IENA seen between 1979 and 1998 who had undergone at least one horizontal surgical procedure. The outcomes in the 16 patients who had previously received botulinum toxin were compared with those in the 28 patients for whom surgery was the primary treatment.


RESULTS
There was a negative correlation between the pretreatment esotropic angle and age (Pearson's r = -0.45, p < 0.05). The first visit to a surgical specialist took place very late (mean age 43 months [standard deviation (SD) 39 months]). Of the 35 children seen during the period in which botulinum toxin was available, 20 (57%) had additional factors inducing unsteadiness of binocular vision (e.g., moderate to severe initial relative amblyopia, initial ametropia). Administration of 5 units of botulinum toxin before 18 months of age destabilized dissociated vertical deviation. Overall, 39 patients (89%) had a final residual deviation of less than 10 prism dioptres. The first surgical correction was horizontal and vertical-torsional in 30 patients (68%). A total of 23 patients (52%) required some retreatment (botulinum toxin or surgery or both). Children treated initially with botulinum toxin had less surgery than those with initial surgery (mean recession or resection 8.9 mm [SD 4.5 mm] vs. 14.2 mm [SD 4.0 mm]) as well as fewer horizontal muscles operated (mean 1.6 [SD 0.6] vs. 2.3 [SD 0.6]).


CONCLUSIONS
Surgery with or without further interventions is a reasonable approach for IENA with delayed diagnosis and in cases associated with unsteadiness of binocular vision or with nonhorizontal deviations. Initial treatment with botulinum toxin, injected into both medial recti, is effective, reducing the amount of further horizontal surgery and favouring postoperative stability, except in children under 18 months, in whom injection of 5 units induces unbalanced dissociated vertical deviation.
Ruiz
Miguel F
MF
Department of Ophthalmology, Ramón y Cajal Hospital, Madrid, Spain. efebocalairis@telefonica.net
Alvarez
María T
MT
Sánchez-Garrido
Carmen M
CM
Hernáez
José M
JM
Rodríguez
José M
JM
D000293:Adolescent; D018726:Anti-Dyskinesia Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D004948:Esotropia / Q000151:congenital / Q000188:drug therapy* / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009759:Nystagmus, Pathologic / Q000188:drug therapy / Q000601:surgery; D009801:Oculomotor Muscles / Q000187:drug effects / Q000601:surgery; D013508:Ophthalmologic Surgical Procedures; D015348:Vision, Binocular; D014792:Visual Acuity
D018726:Anti-Dyskinesia Agents; D019274:Botulinum Toxins, Type A