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  • AAO OTAC Pediatric Ophthalmology/Strabismus Panel, Hoskins Center for Quality Eye Care
    Pediatric Ophth/Strabismus


    A report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Pediatric Ophthalmology/Strabismus Panel. 

    Gil Binenbaum, MD, MSCE,1 Melinda Y. Chang, MD,2 Gena Heidary, MD, PhD,3 David G. Morrison, MD,4 Rupal H. Trivedi, MD, MSCR,5 Jennifer A. Galvin, MD,6 Stacy L. Pineles, MD 

    Ophthalmology, Vol. 128, 1766-1776, ©2021 by the American Academy of Ophthalmology. Click here for free access to the OTA. 

    Purpose: To review the available evidence comparing the effectiveness of extraocular muscle botulinum toxin type A (BXTA) injection with eye muscle surgery for restoring ocular alignment in children and adults with nonparalytic, nonrestrictive horizontal strabismus.

    Methods: Literature searches in the PubMed and Cochrane Libraries, and clinical trial databases with no data restrictions, but limited to articles published in English, were conducted last on January 10, 2021. The searches yielded 515 citations, 40 of which were reviewed in full text by the first author. Fourteen articles met the criteria for inclusion (randomized or nonrandomized comparative studies, or case series with a minimum 50 patients; evaluating extraocular muscle BXTA injection for initial or repeat treatment of horizontal, nonparalytic, nonrestrictive strabismus; with at least 6 months of follow-up) and were graded by a methodologist.

    Results: The 14 included studies consisted of 2 randomized clinical trials, 3 nonrandomized comparative studies, and 9 case series. All 5 comparative studies were graded level II evidence, and the 9 case series were graded level III evidence. Successful motor outcomes after BTXA injection were relatively consistent across 4 of the 5 comparative studies at 60%, when adjustment was made for differential selection bias in 1 of the studies. In the 4 studies, successful motor outcomes after surgery ranged from 66% to 77% with a mean follow-up of 23 to 75 months, and the outcomes were not significantly different from those after BTXA injection. In the fifth level II study, success was significantly higher with BTXA injection than with surgery (94% vs. 72%). The level III BTXA case series demonstrated higher motor success rates of 87% to 89% when children were treated in 2 muscles at a time; rates were lower in adults treated with single-muscle BTXA injection.

    Conclusions: Extraocular muscle injection of BTXA achieves a high rate of successful motor alignment, comparable with that achieved after eye muscle surgery for nonparalytic, nonrestrictive horizontal strabismus. Good alignment may require multiple BXTA injections, and it is not yet clear whether sensory outcomes are equivalent for BTXA injections versus eye muscle surgery in young children. 

    1Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

    2Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California

    3Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts

    4Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee

    5Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina

    6Eye Physicians and Surgeons PC, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut

    7Jules Stein Eye Institute, Los Angeles, California