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

2. 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

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

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

5. 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

6. 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]

7. 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?

8. 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

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

10. Kowal L, Marshman W, Sahare P10 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

11. Kowal L, Marshman W, Sahare P11 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

12. Kowal L, Marshman W, Sahare P12 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

13. 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

14. Kowal L, Marshman W, Sahare P14 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 2 nd Botox shot ‘allowed’

15. 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?

16. Kowal L, Marshman W, Sahare P16 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

17. 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