Kowal L, Marshman W, Sahare P1 Botox Audit 40 cases ≥3mo follow up Retrospective private practice chart review

Kowal L, Marshman W, Sahare P2 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

Kowal L, Marshman W, Sahare P3 Topics of Discussion Results – what we used it for Indications – what it’s good for Problems

Kowal L, Marshman W, Sahare P4 Summary #1 77% (n=31) in office Botox most 2.5 – 5 u [thyroid → 20u] EMG control Repeated if no ‘take’ or inadequate Dr’s discretion 23% (n=9) : intraoperative injection

Kowal L, Marshman W, Sahare P5 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

Kowal L, Marshman W, Sahare P6 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]

Kowal L, Marshman W, Sahare P7 Patient spectrum All ≥ 3 mo follow up 53% ≥ 6 mo follow up Unknown selection bias : How different are those with < 3 mo follow up?

Kowal L, Marshman W, Sahare P8 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

Kowal L, Marshman W, Sahare P9 What we found COMPLICATIONS Ptosis 15% (n=6) Acquired vertical 8% (n=3) ALL RECOVERED

Kowal L, Marshman W, Sahare P10 Table 1 : Esotropia N PRE INJ POST INJ %CHANGE Residual 7 26 ∆ 5 ∆ 59 Consec Large Cong with surgery

Kowal L, Marshman W, Sahare P11 TABLE 2 ESOTROPIA [cont] DIAGNOSIS N PRE INJ POST INJ CHANGE ET after RD Sx % ET after Transp th n paresis Neurological ET All ET

Kowal L, Marshman W, Sahare P12 TABLE 3 HYPO & XT DIAGNOSIS N PRE INJ POST INJ CHANGE Graves’ Iatrogenic vertical ALL HYPO Residual XT Exotropia Consecutive XT ALL XT AASI

Kowal L, Marshman W, Sahare P13 DISCUSSION Retrospective chart analyses not great EBM NO prospective randomised series on Botox for strabismus Otis Paul SKI series n > 200 patient – selected randomisation Low % follow up ARVO not [yet] accepted by refereed jnl Carruthers Smaller prospective series

Kowal L, Marshman W, Sahare P14 DISCUSSION - ET Residual 7 26 ∆ 5 ∆ 59 Consec All ET Reliabilty approaches surgery esp in difficult pts [multiple re-ops] & esp if 2 nd Botox shot ‘allowed’

Kowal L, Marshman W, Sahare P15 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 5 th surgery?

Kowal L, Marshman W, Sahare P16 Suggested scenarios for Botox 25 yo WCF won’t wear gls sc L ET 15, ET’ 25 L amblyopia Consec XT less likely with Botox than surgery

Kowal L, Marshman W, Sahare P17 CONCLUSIONS Botox > 20 y experience NO good studies Useful for ET esp difficult ET LK: recommends for Graves’ hypo