Kowal L, Marshman W, Sahare P 1

Botox Audit

40 cases

≥3mo follow up

Retrospective private practice chart review

Kowal L, Marshman W, Sahare P 2

Introduction

Introduced by Alan Scott in 1979 for adult strabismus

Mechanism :While muscle is totally paralysed,

stretching of this muscle & contracture of active ipsilateral antagonist → new sarcomere density, new L - T curve & new alignment SOME of which persists when paralysis recovers

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Topics of Discussion

Results – what we used it for

Indications – what it’s good for

Problems

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Summary #1

77% (n=31) in office Botox most 2.5 – 5 u [thyroid → 20u] EMG control Repeated if no ‘take’ or inadequate

result @ Dr’s discretion 23% (n=9) : intraoperative injection

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Summary #2

Fairly reliable for residual & consecutive ET

Not reliable in Graves’ and XT Effective as adjunct to surgery in

large angle esotropia Tychsen > 60 ∆ : BMR 6mm + Botox 2.5 to MR > 75 ∆ : ….. + Botox to both medials

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Patient spectrum

Age 3 mo to 80 y (mean 40.5 y) 47% F 53% M 70% eso 20% hypo 10% exo 70% strab ≥ 6 mo 20% strab ≤ 3 mo 55% previous strab surgery [n=2]

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Patient spectrum

All ≥ 3 mo follow up

53% ≥ 6 mo follow up

Unknown selection bias : How different are those with < 3 mo follow up?

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What we did

70% (n=31) Botox to MR 20% (n=8) Botox to IR 10% (n=4) Botox to LR 68% (n=27) 5 u 20% (n=8) 2.5 u 5% (n=2) 7.5 u 8% (n=3) ≥ 10 u

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What we found

COMPLICATIONS

Ptosis 15% (n=6) Acquired vertical 8% (n=3)

ALL RECOVERED

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Table 1 : Esotropia N PRE INJ POST INJ %CHANGE

Residual 7 26 ∆ 5 ∆ 59

Consec 6 32 9 74

Large 5 64 22 66

Cong 1 80 0 100 with surgery

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TABLE 2 ESOTROPIA [cont]

DIAGNOSIS N PRE INJ POST INJ CHANGE ET after RD Sx 2 25 8 75%

ET after Transp 1 18 6 67

6th n paresis 3 27 9 62

Neurological ET 2 22 12 47

All ET 27 36 8 66

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TABLE 3 HYPO & XT

DIAGNOSIS N PRE INJ POST INJ CHANGE Graves’ 6 25 17 36

Iatrogenic vertical 2 15 6 60 ALL HYPO 8 24 15 36

Residual XT 2 22 35 0

Exotropia 1 35 5 85

Consecutive XT 1 25 14 44 ALL XT 4 26 22 32

AASI 1 32 15 53

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DISCUSSION Retrospective chart analyses not great EBM

NO prospective randomised series on Botox for strabismus

Otis Paul SKI series n > 200 patient – selected randomisationLow % follow up ARVO not [yet] accepted by refereed jnl

Carruthers Smaller prospective series

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DISCUSSION - ET Residual 7 26 ∆ 5 ∆ 59

Consec 6 32 9 74

All ET 27 36 8 66

Reliabilty approaches surgery esp in difficult pts [multiple re-ops] & esp if 2nd Botox shot ‘allowed’

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Suggested scenarios for Botox

2 yo cong ET 4 surgeries so far now 45∆ ET R/O +, 6ths, Duanes McNeer / Gomez : Bimedial Botox

repeated prn Can it be less reliable than a 5th

surgery?

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Suggested scenarios for Botox

25 yo WCF + 1.50 won’t wear gls sc L ET 15, ET’ 25 L amblyopia Consec XT less likely with Botox

than surgery

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CONCLUSIONS

Botox > 20 y experience

NO good studies

Useful for ET esp difficult ET

LK: recommends for Graves’ hypo