Botox Audit

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 Kowal L, Marshman W, Sahare P

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

4. 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 Kowal L, Marshman W, Sahare P

5. 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 P

6. 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 P

7. 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 P

8. 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 P

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

10. 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 Kowal L, Marshman W, Sahare P

11. TABLE 2ESOTROPIA [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 Kowal L, Marshman W, Sahare P

12. TABLE 3HYPO & 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 Kowal L, Marshman W, Sahare P

13. 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 P

14. 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’ Kowal L, Marshman W, Sahare P

15. 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? Kowal L, Marshman W, Sahare P

16. 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 Kowal L, Marshman W, Sahare P

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