Usefulness of Botulinum Toxin Type-A in the Treatment of Chronic Sixth Nerve Palsy 3
an important aid in the preoperative evaluation of possi-
ble postoperative diplopia on patients in which this can-
not be done by means of prism or traction test; in acute
paretic loss of ocular muscle function; when surgical
treatment of the ocular muscles is not yet possible but the
patient is obviously affected by diplopia or a forced pos-
ture of the head [2], in situations where strabismus sur-
gery is not suitable (as in elderly patients unfit for gen-
eral anaesthesia; when the clinical condition is evolving
or unstable, or in case of unsuccessful surgery) [13], in
acute Graves’ disease, and especially into VI cranial
nerve paresis [2], or in association with the surgery [14].
Depending on the surgical approach in VI nerve palsies,
Botulinum toxin may be injected in the medial rectus
muscle before muscle transposition surgery to loosen
contracture [2] or, on the basis of our results, BTX-A
injection can be considered an invaluable tool in the
management and diagnosis of VI nerve palsy, and it al-
lows differential diagnosis between paresis vs paralysis,
which is the necessary condition to plan the correct sur-
gical treatment and to obtain a successful functional out-
come. In other strabismus, as congenital esotropia or
horizontal strabismus in adults, Botulinum toxin is defi-
nitely an inferior surgical treatment of the ocular muscles
[2]. Moreover the use of botulinum toxin type A is effi-
cient in the identification of adult patients with constant
strabismus who are at high risk o developing intractable
diplopia after surgery [15]. The majority of studies iden-
tify the Botulinum toxin A injection into extra-ocular
muscles the ideal therapy for the treatment of sixth cra-
nial nerve palsy [1], on 36.8% of the patients with a final
ocular alignment within 10 prism dioptres of orthotropia
and achieved fusion and primary gaze position. There
was no correlation among the number of injection for
patient (the mean number of injection is 1 to 5), the size
of strabismus, the grade of lateral rectus muscle function,
the age, the gender or the time paresis it occurred [1]. In
our study all patients had to undergo a single injection
and only in 32% of cases (9 patients) a gradual physio-
logical recovery of the lateral rectus muscle was obtained
at 6 months like if the surgical treatment could be
avoided and nobody of them was candidate for a second
injection; patients under-corrected at six months from the
onset were been treated with surgery. The most interest-
ing result was to identify in GROUP 1 six patients who
had been suffering with palsy for a period in excess of 24
months before the injection (CLASS I); although it is
known and documented that VI nerve deficit of traumatic
origin tends to normalize without any treatment or after
botulinum toxin injection [7,16,17] this has never been
recorded for cases where patients have been subject to
palsy for such a long time. Moreover it is also possible to
combine the injection with surgery [14] to preserve the
function of the medial rectus muscle, in order to avoid
surgery on more than two rectus muscles to prevent the
risk of anterior segment ischemia (which can occur when
there is surgery of multiple muscles) and to expand the
field of binocular single vision as much as possible. In
our trials, Botulinum toxin type-A (BTX-A) was directly
injected in the hyperfunctional muscle without electro-
myographic assistance, in order to reduce the incidence
of blepharoptosis [18]; a study of 2003 proposed that
subtenon injection of the medial rectus muscle for the
treatment of acute tramatic sixth nerve palsy [19]. The
results on the patients treated with subtenonian injection
of botulinum toxin without electromyography (EMG)
guidance was comparable to that obtained using EMG-
guided intramuscolar injection of botulinum toxin [19,
20], the reason is in fact that the substance injected in the
muscle has the tendency to diffuse into the surrounding
tissues. Finally BTX injection has been used for 11 years
by 292 ophthalmologists in 8854 patients, from the age
of three months to 90 years, in a variety of eye muscle
and eyelid disorders [21]. According to international lit-
erature, no systemic toxin reaction has occurred, local
complications are few and visual loss has not occurred in
any case [21]; ptosis and acquired vertical deviation caused
by diffusion of the substance into the surrounding tissues
are the commonest complications encountered. These are
minor and reversible damages induced by the traumatic
action of the needle and/or the substance into the tissues
(edema and minor subconjunctival hemorrhage), as fur-
ther proof that the repeated use of BTX-A could be con-
sidered safe [13].
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