title: Minimally invasive botulinum toxin type A injection from the ocular surface to extraocular muscles.
abstract: OBJECTIVE
  To investigate a new, safe and effective injection method for strabismus patients. Botulinum toxin type A (BTXA) was injected by pulling the extraocular muscles with a minimally-invasive technique into the ocular surface, and it was ensured that the extraocular muscles was maintained in the suspended state.
  
  
  METHODS
  A total of 32 patients with different types of strabismus were treated at our institution from February to October 2010. A small conjunctival incision (≤2mm) was made under a microscope. The extraocular muscles were pulled out with a hook to ensure an elevated position compared with the wall of eyeball. The muscle fiber was clearly seen through the conjunctiva and BTXA was injected at a small angle under the microscope. The deviation angles before and after the injection were recorded. All patients were followed up at 5 and 30 days after the operation. Recovery was defined as abolition of diplopia in straight-ahead gaze and anteroinferior gaze and the symptoms of giddiness disappeared thoroughly. Eyeball position was essentially normal. Improvement was defined as basic disappearance of diplopia in straight-ahead gaze and anteroinferior gaze; restriction of action of paralytic muscle improved. If most of the symptoms and signs still existed and disturbed normal work and life, the treatment was determined to be invalid. The injection dose for patients of 5 to 10 prism diopter (PD), 11 to 20PD, and ≥21PD was 1u, 3u and 4u to 5u, respectively.
  
  
  RESULTS
  Of the 32 treated patients, 11(34.4%) were cured, and 18(56.3%) were improved at 5 days after the operation; 12(40%) were cured, and 15(46.9%) were improved at 30 days. Five patients (15.6%) who had unsatisfactory response after BTXA injection at 30 days received repeated injections or underwent strabismus surgery. Ptosis was present in 2.5% of the injected eyes. No retrobulbar hemorrhage or ocular perforation was found in any eye.
  
  
  CONCLUSIONS
  It is safe and efficient to inject BTXA by pulling extraocular muscles with a minimally-invasive technique under the microscope to make the muscles separated from the wall of eyeball.
authors.affiliation: College of Medicine, Qingdao University, Qingdao 266071, Shandong Province, China.
authors.forename: Xiao-Mei
authors.initials: XM
authors.lastname: Wan
authors.forename: Rui-Xue
authors.initials: RX
authors.lastname: Chu
authors.forename: Hua-Qing
authors.initials: HQ
authors.lastname: Gong