title: Comparison of botulinum toxin with surgery as primary treatment for infantile esotropia.
abstract: OBJECTIVE
  To compare bilateral medial rectus muscle injection of botulinum toxin with surgery as primary treatment for infantile esotropia.
  
  
  METHODS
  A single-center, prospective, nonrandomized comparative study was undertaken of botulinum toxin versus surgery in children who presented by age 36 months with esotropia onset before 12 months. Successful outcome was defined as ocular alignment within 10Delta of orthotropia after one surgery or 1 to 3 bilateral botulinum injections.
  
  
  RESULTS
  Of 442 subjects, 322 received botulinum toxin (1 injection, 49%; 2, 41%; 3, 10%); 120 had surgery. Motor success was achieved in 66% of surgery patients, compared with 45% of botulinum patients (p < 0.001). Among subjects with deviation >30Delta, surgery achieved 69% success versus 36% with botulinum toxin (relative risk, 1.95; 95% CI, 1.53-2.49). At deviations < or = 30Delta, there was no difference (surgery, 60%; botulinum toxin, 59%; relative risk, 1.03; 95% CI, 0.78-1.35). There were no statistically significant differences in mean pretreatment deviation (botulinum toxin, 38.8Delta; surgery, 38.2Delta) or mean follow-up (botulinum toxin, 22.6 months; surgery, 20.7). Surgery occurred later than botulinum injection (mean age at treatment, 27.0 vs. 16.7 months; p < 0.001) with greater duration of misalignment (21.0 vs 12.5 months, respectively; p < 0.001), but neither variable influenced outcome in multivariate regression.
  
  
  CONCLUSIONS
  In this large, nonrandomized prospective cohort, surgery was more successful than botulinum toxin in the treatment of large-angle esotropia. Botulinum toxin appeared most effective for esotropia <30Delta to 35Delta, with a success rate comparable with surgery. Botulinum toxin may be an alternative to surgery in children with small- to moderate-angle infantile esotropia.
authors.affiliation: Department of Ophthalmology, University of California, San Francisco, San Francisco, CA 94143, USA. dealbaa@vision.ucsf.edu
authors.forename: Alejandra G
authors.initials: AG
authors.lastname: de Alba Campomanes
authors.forename: Gil
authors.initials: G
authors.lastname: Binenbaum
authors.forename: Glorialicia
authors.initials: G
authors.lastname: Campomanes Eguiarte
mesh_terms: D017668:Age of Onset; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002675:Child, Preschool; D004948:Esotropia / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007273:Injections, Intramuscular; D008297:Male; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D009801:Oculomotor Muscles / Q000187:drug effects* / Q000601:surgery*; D013508:Ophthalmologic Surgical Procedures; D011446:Prospective Studies; D016896:Treatment Outcome; D015348:Vision, Binocular / Q000502:physiology
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A