title: Pharmacologic injection treatment of comitant strabismus.
abstract: OBJECTIVE
  To report the magnitude and stability of corrections in comitant horizontal strabismus achieved by injecting bupivacaine (BPX, optionally with epinephrine) and botulinum A toxin (BTXA) into extraocular muscles of alert adult subjects with electromyographic (EMG) guidance.
  
  
  METHODS
  A total of 55 adults with comitant horizontal strabismus participated in a prospective observational clinical series. Of these, 29 previously had undergone 1 or more unsuccessful strabismus surgeries; 4 had undergone other orbital surgeries. Thirty-one patients with esodeviations received BPX injections in a lateral rectus muscle, some with BTXA in the medial rectus; 24 patients with exodeviations received BPX in a medial rectus muscle, some with BTXA in the lateral rectus muscle. A second treatment (BPX, BTXA, or both) was administered to 27 patients who had residual strabismus after the first treatment. Five patients required additional injections. Clinical alignment was measured at 6 months and yearly thereafter through 5 years' follow-up, with mean follow-up of 28 months. A successful outcome was defined as residual deviation ≤10(Δ).
  
  
  RESULTS
  On average, presenting misalignment of 23.8(Δ) (13.4°) was reduced at 28 months by 16.0(Δ) (9.1°), with successful outcomes in 56% of patients. Of patients with initial misalignments ≤25(Δ), 66% had successful outcomes, with corrections averaging 13.2(Δ) (7.5°); of patients with larger misalignments, 40% had successful outcomes, with corrections averaging 20.9(Δ) (11.8°). Corrected alignments were stable over follow-ups as long as 5 years.
  
  
  CONCLUSIONS
  Injection treatments resulted in stable, clinically significant corrections in comitant horizontal strabismus. Injection provides a low-cost alternative to incisional strabismus surgery, particularly where it is desirable to minimize surgical anesthesia and avoid extraocular scarring.
authors.affiliation: Strabismus Research Foundation, Mill Valley, California; Eidactics, San Francisco, California; Hospital das Clinicas of the University of São Paulo, São Paulo, Brazil; Instituto Strabos, São Paulo, Brazil.
authors.forename: Iara
authors.initials: I
authors.lastname: Debert
authors.affiliation: Strabismus Research Foundation, Mill Valley, California; Eidactics, San Francisco, California. Electronic address: jmm@eidactics.com.
authors.forename: Joel M
authors.initials: JM
authors.lastname: Miller
authors.affiliation: Strabismus Research Foundation, Mill Valley, California; Eidactics, San Francisco, California.
authors.forename: Kenneth K
authors.initials: KK
authors.lastname: Danh
authors.affiliation: Strabismus Research Foundation, Mill Valley, California; Eidactics, San Francisco, California.
authors.forename: Alan B
authors.initials: AB
authors.lastname: Scott
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000779:Anesthetics, Local / Q000627:therapeutic use*; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002045:Bupivacaine / Q000627:therapeutic use*; D004338:Drug Combinations; D004576:Electromyography; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D009801:Oculomotor Muscles / Q000187:drug effects* / Q000503:physiopathology; D011446:Prospective Studies; D013285:Strabismus / Q000188:drug therapy* / Q000503:physiopathology; D015348:Vision, Binocular / Q000502:physiology; D055815:Young Adult
chemical_list: D000779:Anesthetics, Local; D004338:Drug Combinations; D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A; D002045:Bupivacaine