June 2015
Volume 56, Issue 7
ARVO Annual Meeting Abstract  |   June 2015
Complications of Botulinum Toxin-A for Treatment of Esotropia in Children
Author Affiliations & Notes
  • Stephen P Christiansen
    Ophthalmology-Boston Med Ctr, Boston University School of Medicine, Boston, MA
  • Danielle Chandler
    Jaeb Center for Health Research, Tampa, FL
  • Katherine A Lee
    St. Luke's Children's Hospital, Boise, ID
  • Rosanne Superstein
    Ophthalmology, Centre Hospitalier Universitaire Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
  • Alejandra G De Alba Campomanes
    Ophthalmology, University of California, San Francisco, San Francisco, CA
  • Erick D, Bothun
    Ophthalmology, University of Minnesota, Minneapolis, MN
  • David K Wallace
    Duke Eye Center, Durham, NC
  • Raymond T Kraker
    Jaeb Center for Health Research, Tampa, FL
  • Footnotes
    Commercial Relationships Stephen Christiansen, None; Danielle Chandler, None; Katherine Lee, None; Rosanne Superstein, None; Alejandra De Alba Campomanes, None; Erick Bothun, None; David Wallace, None; Raymond Kraker, None
  • Footnotes
    Support None
Investigative Ophthalmology & Visual Science June 2015, Vol.56, 1333. doi:
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      Stephen P Christiansen, Danielle Chandler, Katherine A Lee, Rosanne Superstein, Alejandra G De Alba Campomanes, Erick D, Bothun, David K Wallace, Raymond T Kraker, Pediatric Eye Disease Investigator Group; Complications of Botulinum Toxin-A for Treatment of Esotropia in Children. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):1333.

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      © ARVO (1962-2015); The Authors (2016-present)

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To report operative complications in children treated for esotropia by botulinum toxin A (BTX-A) injection.


Subjects <17 years of age with esotropia were enrolled in a 9-month data-collection study following BTX-A injection of one or both medial rectus muscles. Subjects were managed as per investigators’ routine clinical practice. Demographic, historical, and pre-injection clinical data as well as details of the BTX-A injection and perioperative complications were collected at enrollment. Post-injection data from each visit through 9 months was collected retrospectively.


Twenty-seven subjects were enrolled at 13 sites. Esotropia onset occurred before 6 months of age in 13 (48%) subjects and after 6 months of age in 14 (52%). Eight (30%) subjects had prior strabismus surgery, and 1 (4%) had prior BTX-A injection. Mean age at injection was 3.9 ± 3.3 years (9 months to 13.8 years). BTX-A injection was unilateral (n=7) or bilateral (n=20) and dosage ranged from 3.0 to 6.0 units per muscle. Preoperative esodeviation, measured by prism and alternate cover test, ranged from 10 to 65 PD (mean = 26 PD) at distance and from 12 to 65 PD (mean = 28) at near. Four of 27 subjects (15%; 95% confidence interval [CI] = 4% to 34%) experienced a complication from the injection. One subject (4%; 95% CI = 0% to 19%) had a left eye scleral perforation which was noted at the time of injection and was treated by laser retinopexy the same day with good visual and motor outcomes. Three subjects (11%; 95% CI = 2% to 29%) developed tonic pupil noted at the first post-injection visit. All three cases occurred in the left eye of subjects who underwent BTX-A injection by the same surgeon, and were characterized by delayed denervation hypersensitivity to pilocarpine 0.125%. The anisocoria diminished during the data collection period, and there were no visual deficits.


Complications of BTX-A injection were encountered in this small cohort of children with esotropia. Globe perforation is a well-known complication of periocular injection. However, there are few reports of tonic pupil after BTX-A injection. The mechanism of action is unknown, but it may be direct trauma to the ciliary ganglion. Other possible explanations include anticholinergic toxicity from intraconal diffusion of BTX-A affecting the ciliary ganglion and/or intraocular diffusion affecting the pupillary sphincter.


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