Uso da toxina botulínica para correção de estrabismo / Botulinum toxin for strabismus correction

OBJETIVO: Verificar os efeitos da aplicação da toxina botulínica tipo A para o tratamento do estrabismo. MÉTODOS: Realizou-se a aplicação de toxina botulínica tipo A (Prosigne®) em 20 pacientes acompanhados no ambulatório de oftalmologia da Faculdade de Medicina do ABC (FMABC), no período de 2006 a 2009, para o tratamento da esotropia. A aplicação foi realizada em 15 crianças com esotropias menores de 50 dioptrias prismáticas (PD) nos dois músculos retos mediais e em cinco adultos com esotropia secundária à paralisia ou paresia do VI nervo, somente no músculo antagonista ao acometido. A incidência de efeitos indesejáveis também foi avaliada. O tempo de seguimento mínimo foi de três meses. RESULTADOS: Três crianças com esotropia foram submetidas a uma segunda aplicação, totalizando 18 aplicações. Destas, 14 aplicações realizaram no mínimo seis meses de acompanhamento. A idade média no momento da aplicação, no grupo das crianças foi de 1,89(±0,54) anos. O desvio convergente médio antes da aplicação foi de 36,67(±6,18) PD; após uma semana foi de -5,06(±23,05) PD, e após três meses foi de 17,50(±14,51) PD. Aos seis meses de acompanhamento cerca de 50% (7/14) das aplicações apresentaram desvio menor que 10 PD. As complicações apresentadas foram: blefaroptose em 38,89% (7/18) das aplicações e desvio vertical em 11,11% (2/18). Quanto aos pacientes adultos, foram realizadas sete aplicações em cinco pacientes. Neste grupo, o desvio esotrópico médio antes da aplicação foi de 46,43(±23,40) PD; após uma semana foi de 30,71(±30,61) PD; e após 3 meses foi de 41,20(±30,82) PD. Apenas um paciente com paresia apresentou satisfação com o resultado. CONCLUSÃO: Houve melhora do estrabismo com redução do desvio ocular nas crianças após aplicação da toxina botulínica tipo A (Prosigne®).

PURPOSE: Evaluate the results and complications from type A botulinum toxin for strabismus treatment. METHODS: Type A botulinum toxin (Prosigne®) was used in 20 patients from Faculdade de Medicina do ABC (FMABC) ophthalmology ambulatory from 2006 to 2009, for esotropia treatment. The application was performed in 15 children with esotropia smaller than 50 prism diopter (PD) in both medial rectus muscles, and in 5 adults with esotropia due to VI nerve paralysis or paresis, only in the opposite muscle. The incidence of adverse effects was also evaluated. The minimum post-treatment follow up was 3 months. RESULTS: Three esotropic children were submitted to second application. Therefore, 18 applications were done. Of these, 14 were measured at least for six months of follow up. The average age at the time of application, in the children group, was 1.89(±0.54) years. Average convergent deviation before application was 36.67(±6.18) PD, after one week was -5.06(±23.05) PD and after three months was 17.50(±14.51) PD. At six months follow up, less than 10 PD of deviation was found in 50% (7/14) of the applications. The complications were blefaroptosis in 38.89% (7/18) applications, and vertical deviation in 11.11% (2/18). Seven applications in five adults were studied. In this group, average esotropic deviation before application was 46.43(±23.40) PD, after one week was 30.71(±30.61) PD and after three months was 41.20(±30.82) PD. Satisfied results was observed only in one patient from this group. CONCLUSION: Strabismus children got better with ocular deviation reduction after type A botulinum toxin (Prosigne®).

Resultados con la aplicación de toxina botulínica en pacientes con endotropía y retraso psicomotor / Results with botulinum toxin in patients with esotropia and psychomotor deficit

Objetivo: Evaluar los resultados del tratamiento con toxina botulínica en pacientes con endotropía y retraso psicomotor. Material y métodos: Se incluyeron pacientes con endotropía y retraso del desarrollo psicomotor menores de siete años, en tratamiento de rehabilitación y sin cirugía previa. Se les realizó exploración oftalmológica y estrabológica completa incluyendo cicloplejía con atropina a 1 %. Se aplicó toxina botulínica en ambos rectos internos bajo sedación y se evaluaron los resultados a la semana, al mes, a los tres y seis meses y al año. Se decidió reinyección si se obtuvo endotropía residual mayor de 25 dioptrías (dp) antes de los tres meses de la primera aplicación. Se consideró un buen resultado cuando hubo desviación dentro de las 10 dp y variabilidad menor o igual a 10 dp. Resultados: Se incluyeron 32 pacientes, 14 mujeres y 18 hombres. El rango de edad era de cinco meses a cinco años, con un promedio de 16.8 meses. Se encontraron 18 pacientes con variabilidad en el ángulo de desviación de 20 a 45 dp de endotropía y 14 sin variabilidad, con un promedio de 39.12 dp. Se reinyectaron 13 pacientes. En 10 pacientes hubo buen resultado, en 17 regular y en cinco malo. Los malos resultados fueron por persistencia de variabilidad importante en cuatro pacientes y en uno hipertropía mayor de 15 dp.Conclusiones: La aplicación de toxina botulínica es una alternativa terapéutica en pacientes con endotropía y retraso psicomotor.

OBJECTIVE: We undertook this study to evaluate the results of the treatment with botulinum toxin in patients with esotropia and psychomotor delay. METHODS: Patients with esotropia and delayed psychomotor development, in rehabilitation therapy and without previous surgery were included. A complete ophthalmological and strabismological exploration was performed including cycloplegic refraction with atropine 1%. Botulinum toxin was applied under sedation in both internal recti. Results were evaluated 1 week, 1 month, 3 and 6 months and after 1 year of application. The reinjection was decided if a 25 DP esotropia or greater was obtained before 3 months of the first application. A good result was considered in patients who had 10 DP of deviation and variability <10 DP. RESULTS: Thirty two patients were included. There were 14 were women and 18 men with an age range from 5 months to 5 years (average 16.8 months). Eighteen patients had variability in the angle of deviation from 20 to 45 DP of esotropia and 14 without variability with an average of 39.12 DP. Thirteen patients were reinjected. A good result was obtained in 10 patients, fair in 17 patients and poor in 5 patients due to persistence of variability in four cases and 15 DP hypertropia in one. CONCLUSIONS: Application of botulinum toxin is a therapeutic alternative in patients with esotropia and psychomotor delay.

Botulinum toxin A in surgically overcorrected and undercorrected strabismus.

OBJECTIVE: To evaluate the effectiveness and safety of botulinum toxin A injection in treating overcorrected and undercorrected strabismus after unsatisfactory postoperative alignment. MATERIAL AND METHOD: The authors reviewed the outcomes of 20 patients aged 5 to 56 years (mean 29.1 years) who had botulinum toxin A injection following their unsatisfactory operation. The motor outcomes (percentage of successful motor outcome and percentage change in deviation) were recorded at 1 month, 3 months, 6 months, I year 2 years, 3 years, and 4 years after botulinum toxin injection. RESULTS: The mean pre-botulinum toxin injection angle of deviation was 20.6 prism dioptors (PD). Six of 20 (30%) patients maintained the successful position for the average of 2.66 years (range 1-4 years) with single injection. The mean percentage change of the deviation was 87.50%, 87.93 %, 73.05 % at 1, 2, and 3-year visit respectively. In 3 of 5 (60%) patients of consecutive esotropia, 4 of 8 (50%) residual esotropia, 1 of 4 (25%) of consecutive exotropia and 1 of 3 (33.33%) of residual exotropia had successful motor alignment at 6 month visit. There was no scleral perforation, visual loss, or retrobulbar hemorrhage from the injection treatment in the present study. CONCLUSION: Botulinum toxin A injection appears to be a safe and effective treatment for overcorrected and undercorrected strabismus after unsatisfactory surgery. It is very effective in rapid elimination postoperative diplopia. When the result is not adequate or the effect does not last long, repeat the injection or reoperation can be chose to perform later.

Aparición de incomitancia lejos-cerca y de un componente acomodativo en la endotropia congénita tratada con toxina botulínica / Appearance of incomitance far-near and accommodative component in congenital esotropia treated with botulinum toxin

Objetivo: Este trabajo intenta estimar la aparición de inconcomitancia lejos-cerca y de un componente acomodativo en pacientes con endotropia congénita tratados con toxina botulínica. Métodos: Para ello hemos realizado un estudio retrospectivo de 26 pacientes con endotropia congénita, menores de tres años, tratados con TB sin I-LC ni componente acomodativo al inicio. El 42 por ciento de los pacientes se corrigió con toxina botulínica. La densidad de incidencia de I-LC fue de 0,079 pacientes-año. Resultados: Un 42,31 por ciento de los pacientes desarrollaron distinto grado de componente acomodativo. La aparición de ambos factores puede condicionar nuestras indicaciones quirúrgicas.

Purpose: Estimate the presence of convergence excess and refractive deviation in a group of patients with infantile esotropia treated with botulinic toxin. Method: Retrospective analysis of 26 patients with infantile esotropia treated with botulinic toxin before the age of three without convergence excess or refractive factor in their deviation. Results: 42 percent were controlled with botulinic toxin. The subsequent incidence of convergence excess was 0,079 patients/year. 42,31 percent of patients developed some degree of refractive component in their deviation. Both factors can modify our surgical indications.

Modificación del estrabismo vertical tras inyección de toxina botulínica A en la endotropía infantil / Modification of vertical strabismus after injection of botulinum toxin A in children esotropia

Introducción y objetivos: Analizar la modificación del estrabismo vertical tras la corrección de la endotropía con Toxina Botulínica (TB). Métodos: 51 endotropías consecutivas, tratadas con TB por debajo de 36 meses de edad. Resultados: 51.85 por ciento de las endotropías congénitas (EC) y 12.5 por ciento de las endotropías adquiridas (ETA) requirieron cirugía vertical. Cuando se corrigió la desviación horizontal, se redujo la necesidad de cirugía vertical a 38.51 por ciento (EC) y 4.54 por ciento (ETA) respectivamente. También se modificaron los patrones alfabéticos. Conclusiones: Se debe ser cauto en la indicación de la cirugía vertical asociada a un cuadro horizontal en la primera infancia.

Introduction and objectives: To study changes in vertical strabismus following treatment of esotropia using Botulinum Toxin. Methods: Fifty one consecutive patients with esotropia treated with Botulinum Toxin at the age of 36 months or less. Results: 51.85 percent of congenital esotropias (CE) and 12.5 percent of acquired esotropias (AET) required vertical surgery. When the horizontal deviation was completely corrected the requirement for vertical surgery was reduced to 38.51 percent (CE) y 4.54 percent (AET) respectively. Alphabet patterns were also affected. Conclusions: One should be cautious about the indications for vertical surgery associated with esotropia in early infancy.

Uso de toxina botulínica en endotropía precoz: resultados a largo plazo / Effect of botulinum toxin in early esotropia: long term outcome

Introducción: Observar el efecto de toxina botulínica sobre el ángulo de estrabismo y la visión binocular a largo plazo. Método: Estudio prospectivo en el que se reclutó pacientes de difícil medición con endotropía precoz. Se hizo seguimiento postinyección única de toxina botulínica en ambos rectos medios. Resultados: Se trataron 13 pacientes. Todos presentaron paresia de rectos medios en los primeros días. 2 pacientes mantuvieron ortotropía durante al menos 3, 5 años. En los 11 restantes reapareció la endotropía, requiriendo 10 de ellos cirugía. El ángulo preoperatorio era en promedio 14 dioptrías prismáticas menor al inicial. 7 de 13 pacientes alcanzaron visión binocular con fusión y 2 visión simultánea. Conclusión: La toxina botulínica no fue un tratamiento definitivo, pero disminuyó el ángulo y mejoró el pronóstico de la visión binocular.