Prospects for the Botulinum Toxin Use in the Treatment of Children`s Strabismus. Review

The review presents information concerning the botulinum toxin use in the treatment of children`s strabismus; highlights aspects of the safety and the complications frequency. It contains information about the methods and doses of botulinum toxin injection, and also considers the cases of necessity of further surgery. There are several ways of introducing BTA: the traditional transconjunctival method of administration under the control of electromyography, used by most ophthalmologists, is not acceptable for treating pediatric patients, transconjunctivally into the subtenon space 10 mm from the limbus into the projection zone of the medial rectus muscle using a 1.0 ml tuberculin syringe with 27G needle, introduction to the muscle with the opening of the conjunctiva, which is safer, is carried out under complete visual control and with the release of extraocular muscle. According to the domestic and foreign literature data we can conclude that the injection of botulinum toxin may be an alternative or complement to surgical techniques, injection of botulinum toxin in the treatment of strabismus in children may be an alternative or complement to surgical and pleopto-orthopto-diploptic correction methods, although not in all clinical cases. The treatment approach of such patients should be comprehensive. There are reports that BoNT-A reduces eye deflection in more than 50 % of patients and provides satisfactory long-term results in infants and children. The average safe dose for Botox is 1-3 units for the muscle. The frequency of complications increases with higher doses (especially> 10 units) and with the transconjunctival route of administration without electromyographic control. This clinical example illustrates the effectiveness of botulinum toxin for the non-concomitant strabismus treatment.

botulinum toxin, chemodenervation, children strabismus, oculomotor disorders

1. Dhaked R.K., Singh M.K., Singh P., Gupta P. Botulinum toxin: bioweapon & magic drug. Indian J Med Res. 2010;132:489–503.

2. Scott A.B., Rosenbaum A., Collins C.C. Pharmacologic weakening of extraocular muscles. Invest Ophthalmol. 1973;12:924–927.

3. Scott A.B. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. J Pediatr Ophthalmol Strabismus. 1980;17:21–25.

4. Dutton J.J., Fowler A.M. Botulinum toxin in ophthalmology. Surv Ophthalmol. 2007;52:13–31. DOI: 10.1016/j.survophthal.2006.10.003

5. Başar E., Arıcı C. Use of Botulinum Neurotoxin in Ophthalmology. Turk J Ophthalmol. 2016 Dec;46(6):282–290. DOI: 10.4274/tjo.57701

6. Ameri A., Mirmohammadsadeghi A., Makateb A., Bazvand F., Hosseini S. Clinical outcomes of botulinum toxin injection in patients with cerebral palsy and esotropia. Strabismus. 2015;23(1):8–13. DOI: 10.3109/09273972.2014.999798

7. Plisov I.L., Atamanov V.V. Experience of using Botulinum toxin-A in the pathology of the oculomotor system. Russian ophthalmology online = Rossijskaya oftal’mologiya onlajn. 2011-01-05T01:36:20Z (In Russ.).

8. Crouch E.R. Use of botulinum toxin in strabismus. Curr Opin Ophthalmol. 2006;17:435–440. DOI: 10.1097/01.icu.0000243018.97627.4c

9. Plisov I.L., Cherhykh V.V., Atamanov V.V., Antsiferova N.G., Pushchina V.B., Istomina T.K. Botox’s Place in the Complex Treatment of Oculomotor System Pathology (the Optimal “Portrait” of the Patient for the Chemodenervation). Оphthalmology in Russia = Oftal’mologiya. 2018;15(2S):261–267 (In Russ.). DOI: 10.18008/18165095-2018-2S-261-267

10. Tengtrisorn S., Treyapun N., Tantisarasart T. Botulinum A toxin therapy on esotropia in children. J Med Assoc Thai. 2002;85:1189–1197.

11. Lambert S.R., Shainberg M.J. The Efficacy of Botulinum Toxin Treatment for Children with a Persistent Esotropia Following Bilateral Medial Rectus Recessions and Lateral Rectus Resections. Am Orthopt J. 2013; 63: 24–28. DOI: 10.3368/aoj.63.1.24

12. Filippova O.A., Hatkova S.E. Botulinum therapy in post-traumatic strabismus and diplopia treatment. Ophthalmology journal = Oftal’mologicheskie vedomosti. 2017;10(1):70–76 (In Russ.).

13. Sener E.C., Sanac A.S. Efficacy and complications of dose increments of botulinum toxin-A in the treatment of horizontal comitant strabismus. Eye (Lond). 2000; 14:873–878. DOI: 10.1038/eye.2000.240

14. Han S.H., Lew H., Jeong C.W., Lee J.B. Effect of botulinum toxin A chemodenervation in sensory strabismus. J Pediatr Ophthalmol Strabismus. 2001;38:68–71.

15. Başar E. Esotropia. Eye diseases in children. İstanbul: Martı Ofset. 2009:177–182.

16. Wan M.J., Mantagos I.S., Shah A.S., Kazlas M., Hunter D.G. Comparison of botulinum toxin with surgery for the treatment of acute-onset comitant esotropia in children. Am J Ophthalmol. 2017;176:33–39. DOI: 10.1016/j.ajo.2016.12.024

17. Ruiz M.F., Moreno M., Sanchez-Garrido C.M., Rodriguez J.M. Botulinum treatment of infantile esotropia with abduction nystagmus. J Pediatr Ophthalmol Strabismus. 2000;37:196–205.

18. Campos E.C., Schiavi C., Bellusci C. Critical age of botulinum toxin treatment in essential infantile esotropia. J Pediatr Ophthalmol Strabismus. 2000;37:328–332. 19. Metz H.S., Dickey C.F. Treatment of unilateral acute sixth-nerve palsy with botulinum toxin. Am J Ophthalmol. 1991;112:381–384.

19. Yabaş Ö., Ziylan Ş., Zorlutuna N., Doruga İ. Botulinum toxin in acute sixth nerve palsy. Turk J Ophthalmol. 2006;36:276–280. 21. Ameri A., Farzbod F., Bazvand F., Mirmohammadsadeghi A., Akbari M., Anvari F., Hosseini S. Botulinum toxin injection in the patients with Duane syndrome type 1. J Curr Ophthalmol. 2017 Mar;29(1):50–53. DOI: 10.1016/j.joco.2016.09.004

20. Speeg-Schatz C., Burgun P., Gottenkiene S. To what extent may Botulinum toxin type A injections be an alternative choice to surgery in infantile esotropia? Eur J Ophthalmol. 2017 May 11;27(3):285–288. DOI: 10.5301/ejo.5000947

21. Solebo A.L., Austin A.-M., Theodorou M., Timms C., Hancox J., Adams G.G.W. Botulinum toxin chemodenervation for childhood strabismus in England: National and local patterns of practice. 2018 June 14. PLoS ONE. 13(6):e0199074. DOI: 10.1371/journal.pone.0199074

22. Tsui J.K. Botulinum toxin as a therapeutic agent. Pharmacol Ther. 1996;72:13–20.

23. Monheit G., Carruthers A., Brandt F., Rand R. A randomized, double-blind, placebo-controlled study of botulinum toxin type A for the treatment of glabellar lines: determination of optimal dose. Dermatol Surg. 2007;33:51–59. DOI: 10.1111/j.1524-4725.2006.32332.x

24. Kane M.A., Brandt F., Rohrich R.J., Narins R.S., Monheit G.D., Huber M.B. Reloxin Investigational G. Evaluation of variable-dose treatment with a new U.S. Botulinum Toxin Type A (Dysport) for correction of moderate to severe glabellar lines: results from a phase III, randomized, double-blind, placebo-controlled study. Plast Reconstr Surg. 2009;124:1619–1629. DOI: 10.1097/PRS.0b013e3181b5641b

25. Zheng L., Azar D. Angle-closure glaucoma following periorbital botulinum toxin injection. Clin Experiment Ophthalmol. 2014;42:690–693. DOI: 10.1111/ceo.12293

26. Corridan P., Nightingale S., Mashoudi N., Williams A.C. Acute angle-closure glaucoma following botulinum toxin injection for blepharospasm. Br J Ophthalmol. 1990;74:309–310.

27. Liu M., Lee H.C., Hertle R.W., Ho A.C. Retinal detachment from inadvertent intraocular injection of botulinum toxin A. Am J Ophthalmol. 2004;137:201–202.

28. Efimova E.L. The application of type A botulinum toxin for the treatment of patients presenting with various forms of strabismus. Russian Pediatric Ophthalmology = Rossiiskaya pediatricheskaya oftal’mologiya. 2017; 12(3):153–162 (In Russ.).

29. Trubilin V.N., Poluninа E.G., Andzhelova D.V., Kurenkov V.V Kapkova S.G., Chinenova K.V. Homeostasis Changes of Tear-Producing System with the Background of Cosmetic Procedures in Periorbital Area. Оphthalmology in Russia = Oftal’mologiya. 2018;15(4):424–432. DOI: 10.18008/1816-5095-2018-4-424-432 (In Russ.).