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Alattar S, Saad MS, Rashed GED, Anwar M. Botulinum toxin augmented surgery versus conventional surgery in the management of large-angle concomitant esotropia: A randomized clinical trial. Oman J Ophthalmol 2024; 17:84-90. [PMID: 38524328 PMCID: PMC10957060 DOI: 10.4103/ojo.ojo_106_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/19/2023] [Accepted: 09/23/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND The surgical management of large-angle concomitant esotropia is challenging with high reoperation rates. This study aims to assess the effectiveness and safety of intraoperative botulinum toxin A (BTA) augmentation compared to surgery alone in large angle concomitant esotropia. MATERIALS AND METHODS This is a prospective randomized interventional study. Patients with large angle concomitant esotropia (≥55 prism diopter [PD]) were randomly allocated to either surgery only (Group I) or BTA augmented surgery (Group II). The surgical effect in PD/mm was calculated and compared between the study groups at all follow up intervals. Treatment was considered successful if the patients had orthotropia ± 10 PD at their final examinations. RESULTS A total of 23 patients were included in the study, 11 in Group I and 12 in group II. The surgical effect was significantly greater in Group II compared to Group I at all follow up durations. The 1-year surgical effect was 32.5% greater in Group II compared to Group I (5.99 ± 0.69 vs. 4.52 ± 0.91 PD/mm, respectively, P = 0.001). The success rate was greater for Group II compared to Group I (75% vs. 63.64%, respectively), but this difference was not statistically significant (P = 0.901). CONCLUSION Botulinum toxin augmented surgery is a good alternative to surgery alone in the treatment of large angle concomitant esotropia. BTA injection exerts a significant augmentation effect on medial rectus muscle recessions.
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Affiliation(s)
- Sara Alattar
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed Sayed Saad
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Gamal El-Deen Rashed
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed Anwar
- Department of Ophthalmology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Bort-Martí AR, Rowe FJ, Ruiz Sifre L, Ng SM, Bort-Martí S, Ruiz Garcia V. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev 2023; 3:CD006499. [PMID: 36916692 PMCID: PMC10012406 DOI: 10.1002/14651858.cd006499.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The use of botulinum toxin as an investigative and treatment modality for strabismus is well reported in the medical literature. However, it is unclear how effective it is in comparison with other treatment options for strabismus. OBJECTIVES The primary objective was to examine the efficacy of botulinum toxin therapy in the treatment of strabismus compared with alternative conservative or surgical treatment options. This review sought to ascertain those types of strabismus that particularly benefit from the use of botulinum toxin as a treatment option (such as small angle strabismus or strabismus with binocular potential, i.e. the potential to use both eyes together as a pair). The secondary objectives were to investigate the dose effect and complication rates associated with botulinum toxin. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS and three trials registers on 6 July 2022, together with reference checking to identify additional studies. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA We planned to include randomized controlled trials (RCTs) comparing botulinum toxin with strabismus surgery, botulinum toxin alternatives (i.e. bupivacaine) and conservative therapy such as orthoptic exercises, prisms, or lens therapy for people of any age with strabismus. All relevant RCTs identified in this update compared botulinum toxin with strabismus surgery. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane and assessed the certainty of the body of evidence using GRADE. MAIN RESULTS We included four RCTs with 242 participants that enrolled adults with esotropia or exotropia, children with acquired esotropia, and children with infantile esotropia. The follow-up period ranged from six to 36 months. Two studies were conducted in Spain, and one each in Canada and South Africa. We judged the included studies to have a mixture of low, unclear and high risk of bias. We did not consider any of the included studies to be at low risk of bias for all domains. All four studies reported the proportion of participants who improved or corrected strabismus, defined as ≤ 10 prism diopters (PD) at six months (two studies) or ≤ 8 PD at one year (two studies). Low-certainty evidence suggested that participants treated with the surgery may be more likely to improve or correct strabismus compared with those who treated with botulinum toxin (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.53 to 0.99; I² = 50%; 4 studies, 242 participants; low-certainty evidence). One study, which enrolled 110 children with infantile esotropia, suggested that surgery may reduce the incidence of additional surgical intervention required, but the evidence was very uncertain (RR 3.05, 95% CI 1.34 to 6.91; 1 study, 101 participants; very low-certainty evidence). Two studies conducted in Spain compared botulinum toxin with surgery in children who required retreatment for acquired or infantile esotropia. These two studies provided low-certainty evidence that botulinum toxin may have little to no effect on achieving sensory fusion (RR 0.88, 95% CI 0.63 to 1.23; I² = 0%; 2 studies, 102 participants) and stereopsis (RR 0.86, 95% CI 0.59 to 1.25; I² = 0%; 2 studies, 102 participants) compared with surgery. Three studies reported non-serious adverse events. Partial transient ptosis (range 16.7% to 37.0%) and transient vertical deviation (range 5.6% to 18.5%) were observed among participants treated with botulinum toxin in three studies. In one study, 44.7% participants in the surgery group experienced discomfort. No studies reported serious adverse events or postintervention quality of life. AUTHORS' CONCLUSIONS It remains unclear whether botulinum toxin may be an alternative to strabismus surgery as an independent treatment modality among certain types of strabismus because we found only low and very low-certainty evidence in this review update. Low-certainty evidence suggests that strabismus surgery may be preferable to botulinum toxin injection to improve or correct strabismus when types of strabismus and different age groups are combined. We found low-certainty evidence suggesting botulinum toxin may have little to no effect on achievement of binocular single vision compared with surgery in children with acquired or infantile esotropia. We did not find sufficient evidence to draw any meaningful conclusions with respect to need for additional surgery, quality of life, and serious adverse events. We identified three ongoing trials comparing botulinum toxin with conventional surgeries in the varying types of strabismus, whose results will provide relevant evidence for our stated objectives. Future trials should be rigorously designed, and investigators should analyze outcome data appropriately and report adequate information to provide evidence of high certainty. Quality of life and cost-effectiveness should be examined in addition to clinical and safety outcomes.
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Affiliation(s)
| | - Fiona J Rowe
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | | | - Sueko M Ng
- Department of Ophthalmology, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Vicente Ruiz Garcia
- Hospital at Home Unit, Tower C, Floor 1 Office 5 & CASPe Spain, La Fe University Hospital, Valencia, Spain
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Gjosevska Dashtevska E, Ivanova Cekov M, Jakjovski K. Botilinum toxin in the treatment of strabismus. MAKEDONSKO FARMACEVTSKI BILTEN 2023. [DOI: 10.33320/maced.pharm.bull.2022.68.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Introduction: Strabismus is an oculomotor imbalance that occurs in 0.5 to 5% of the population. There are various etiopathogenetic theories and several modalities of treatment. One of these modalities is the application of botulinum toxin intramuscularly. This chemodenervation causes temporary muscle paresis which acts as a recession while its antagonist contracts. This achieves a temporary correction of strabismus. However, further research is needed. The aim of the paper was evaluation of published research studies on botulinum toxin as a treatment option in strabismus, as a primary and adjuvant therapy and as a preventive therapy in patients with abducens nerve palsy.
For this purpose, we searched the major databases of the medical publications Medline and Pubmed, using keywords: strabismus, botulinum toxin. We found more than 50 articles related to our search for the last 30 years, 30 of which have been used for this review. In this review paper we have presented the most important insights from the literature, as well as our opinions and insights on the topic. Although further studies are needed regarding dosing as well as avoiding side effects, botulinum toxin has been shown to be a good alternative and adjunctive therapy to strabismus surgery, with the downside being that the effect is temporary. Positive effects and faster recovery have also been shown in patients with abducens nerve palsy.
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Affiliation(s)
- Emilija Gjosevska Dashtevska
- University Clinic for Eye Diseases, Faculty of Medicine, Ss. Cyril and Methodious University in Skopje, Mother Theresa 47, 1000 Skopje, Republic of North Macedonia
| | - Maja Ivanova Cekov
- Faculty of Medicine, Ss. Cyril and Methodious University in Skopje, Mother Theresa 47, 1000 Skopje, Republic of North Macedonia
| | - Krume Jakjovski
- Faculty of Medicine, Ss. Cyril and Methodious University in Skopje, Mother Theresa 47, 1000 Skopje, Republic of North Macedonia
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Teixeira JAM, Mesquita MTAM, Demachki NT, Nakanami CR, Mendonça TFS. Transplante autólogo de músculo ocular extrínseco para tratamento cirúrgico de estrabismos sensoriais grandes. REVISTA BRASILEIRA DE OFTALMOLOGIA 2021. [DOI: 10.37039/1982.8551.20210032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Botulinum toxin is an important treatment for many conditions in ophthalmology, including strabismus, nystagmus, blepharospasm, hemifacial spasm, spastic and congenital entropion, corneal exposure, and persistent epithelial defects. The mechanism of action of botulinum toxin for both strabismus and nystagmus is the neuromuscular blockade and transient paralysis of extraocular muscles, but when botulinum toxin is used for some forms of strabismus, a single injection can convey indefinite benefits. There are two unique mechanisms of action that account for the long-term effect on ocular alignment: (1) the disruption of a balanced system of agonist-antagonist extraocular muscles and (2) the reestablishment of central control of alignment by the binocular visual system. For other ocular conditions, botulinum toxin acts through transient paralysis of periocular muscles. Botulinum toxin is a powerful tool in ophthalmology, achieving its therapeutic effects by direct neuromuscular blockade of extraocular and periocular muscles and by unique mechanisms related to the underlying structure and function of the visual system.
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Al Jabri S, Kirkham J, Rowe FJ. Development of a core outcome set for amblyopia, strabismus and ocular motility disorders: a review to identify outcome measures. BMC Ophthalmol 2019; 19:47. [PMID: 30736755 PMCID: PMC6368710 DOI: 10.1186/s12886-019-1055-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 01/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Core Outcome Sets (COS) are defined as the minimum sets of outcomes that should be measured and reported in all randomised controlled trials to facilitate combination and comparability of research. The aim of this review is to produce an item bank of previously reported outcome measures from published studies in amblyopia, strabismus and ocular motility disorders to initiate the development of COS. METHODS A review was conducted to identify articles reporting outcome measures for amblyopia, strabismus and ocular motility disorders. Using systematic methods according to the COMET handbook we searched key electronic bibliographic databases from 1st January 2011 to 27th September 2016 using MESH terms and alternatives indicating the different subtypes of amblyopia, strabismus and ocular motility disorders in relation to treatment outcomes and all synonyms. We included Cochrane reviews, other systematic reviews, controlled trials, non-systematic reviews and retrospective studies. Data was extracted to tabulate demographics of included studies, primary and secondary outcomes, methods of measurement and their time points. RESULTS A total of 142 studies were included; 42 in amblyopia, 33 in strabismus, and 68 in ocular motility disorders (one study overlap between amblyopia and strabismus). We identified ten main outcome measure domains for amblyopia, 14 for strabismus, and ten common "visual or motility" outcome measure domains for ocular motility disorders. Within the domains, we found variable nomenclature being used and diversity in methods and timings of measurements. CONCLUSION This review highlights discrepancies in outcome measure reporting within published literature for amblyopia, strabismus and ocular motility and it generated an item bank of the most commonly used and reported outcome measures for each of the three conditions from recent literature to start the process of COS development. Consensus among all stakeholders including patients and professionals is recommended to establish a useful COS.
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Affiliation(s)
- Samia Al Jabri
- Department of Health Services Research, University of Liverpool, Waterhouse Building Block B, 2nd Floor, 1-3 Brownlow Street, L69 3GL Liverpool, UK
| | - Jamie Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Fiona J. Rowe
- Department of Health Services Research, University of Liverpool, Waterhouse Building Block B, 2nd Floor, 1-3 Brownlow Street, L69 3GL Liverpool, UK
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Botulinum toxin as an adjunct to monocular recession-resection surgery for large-angle sensory strabismus. J AAPOS 2017; 21:117-120. [PMID: 28315737 DOI: 10.1016/j.jaapos.2017.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/15/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the result of using intraoperative botulinum toxin A (BTA) as an adjunct to monocular recession-resection surgery in the management of large-angle sensory strabismus. METHODS The medical records of patients diagnosed with sensory strabismus with constant large-angle strabismus were reviewed retrospectively to identify those who underwent monocular recession-resection surgery combined with 5 units of BTA injection into the recessed muscle of the nonfixating eye. Surgical outcome was considered successful if the final deviation was within the range of 0Δ-10Δ. RESULTS A total of 13 patients (mean age, 31.04 ± 18.5 years) were included, 8 with exotropia and 5 with esotropia. The mean follow-up period was 52.77 ± 10.9 months. The mean preoperative deviation was 66Δ ± 16Δ in the esodeviation group and 56Δ ± 5Δ in the exodeviation group. The final postoperative mean deviation was 6Δ ± 7Δ in the esodeviation group and 6Δ ± 8Δ in the exodeviation group. There were 7 patients (87.5%) with final deviation of ≤10Δ in the exodeviaton group and 4 (80%) in the esodeviation group. CONCLUSIONS Adjunctive usage of BTA with conventional surgery appears to enhance surgical outcomes by increasing the amount of expected correction. The combined use of BTA with monocular recession-resection rectus muscle surgery may be a good alternative in the treatment of large-angle sensory strabismus with the advantage of less risk of potential complications compared to supramaximal surgery or surgery in the "good" eye.
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Abstract
BACKGROUND The use of botulinum toxin as an investigative and treatment modality for strabismus is well reported in the medical literature. However, it is unclear how effective it is in comparison to other treatment options for strabismus. OBJECTIVES The primary objective was to examine the efficacy of botulinum toxin therapy in the treatment of strabismus compared with alternative conservative or surgical treatment options. This review sought to ascertain those types of strabismus that particularly benefit from the use of botulinum toxin as a treatment option (such as small angle strabismus or strabismus with binocular potential, i.e. the potential to use both eyes together as a pair). The secondary objectives were to investigate the dose effect and complication rates associated with botulinum toxin. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2016), Embase (January 1980 to July 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 July 2016. We handsearched the British and Irish Orthoptic Journal, Australian Orthoptic Journal, proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA) and International Orthoptic Association (IOA) (www.liv.ac.uk/orthoptics/research/search.htm) and American Academy of Paediatric Ophthalmology and Strabismus meetings (AAPOS). We contacted researchers who are active in this field for information about further published or unpublished studies. SELECTION CRITERIA We included randomised controlled trials (RCTS) of any use of botulinum toxin treatment for strabismus. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. We used standard methods expected by Cochrane and assessed the certainty of the evidence using GRADE. We defined ocular alignment as an angle of deviation of less than or equal to 10 prism dioptres. MAIN RESULTS Six RCTs were eligible for inclusion. We judged the included studies as at a mixture of low, unclear and high risk of bias. We did not consider any of the included studies as at low risk of bias for all domains.Two trials conducted in Spain (102 people, number of eyes not specified) compared botulinum toxin with surgery in children that required retreatment for acquired or infantile esotropia. These two studies provided low-certainty evidence that children who received botulinum toxin may have a similar or slightly reduced chance of achieving ocular alignment (pooled risk ratio (RR) 0.91, 95% confidence interval (CI) 0.71 to 1.16), binocular single vision (RR 0.88, 95% CI 0.63 to 1.23), sensory fusion (RR 0.88, 95% CI 0.63 to 1.23) and stereopsis (RR 0.86, 95% CI 0.59 to 1.25) compared with children who received surgery. One trial from Canada compared botulinum toxin with surgery in 30 adults (30 eyes) with horizontal strabismus and reported a reduced chance of ocular alignment with botulinum toxin (RR 0.38, 95% CI 0.17 to 0.85; low-certainty evidence).One trial in the UK suggested that botulinum toxin may result in a similar or slightly improved chance of ocular alignment in people with acute onset sixth nerve palsy compared with observation (RR 1.19, 95% CI 0.96 to 1.48; 47 participants, low-certainty evidence).Very low-certainty evidence from one trial from Brazil suggested that adjuvant botulinum toxin in strabismus surgery may increase the chances of ocular alignment compared with strabismus surgery alone (RR 1.83, 95% CI 0.41 to 8.11; 23 participants).One trial from China of 47 participants (94 eyes) suggested that people receiving botulinum toxin combined with sodium hyaluronate may have a similar or slightly reduced chance of achieving ocular alignment compared with botulinum toxin alone (RR 0.81, 95% CI 0.36 to 1.82; low-certainty evidence).Reported complications in people given botulinum toxin in the included trials included ptosis (range 9% to 41.66%) and vertical deviation (range 8.3% to 18.51%). Ptosis occurred less frequently when treated with botulinum toxin combined with sodium hyaluronate compared to botulinum toxin alone. AUTHORS' CONCLUSIONS Most published literature on the use of botulinum toxin in the treatment of strabismus consists of retrospective studies, cohort studies or case reviews. Although these provide useful descriptive information, clarification is required as to the effective use of botulinum toxin as an independent treatment modality. Six RCTs on the therapeutic use of botulinum toxin in strabismus, graded as low and very low-certainty evidence, have shown varying responses. These include a lack of evidence for effect of botulinum toxin on reducing visual symptoms in acute sixth nerve palsy, poor response in people with horizontal strabismus without binocular vision, similar or slightly reduced achievement of successful ocular alignment in children with esotropia and potential increased achievement of successful ocular alignment where surgery and botulinum toxin are combined. Further high quality trials using robust methodologies are required to compare the clinical and cost effectiveness of various forms of botulinum toxin (e.g. Dysport, Xeomin, etc), to compare botulinum toxin with and without adjuvant solutions and to compare botulinum toxin to alternative surgical interventions in strabismus cases with and without potential for binocular vision.
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Affiliation(s)
- Fiona J Rowe
- University of LiverpoolDepartment of Health Services ResearchWaterhouse Building (B211)1‐3 Brownlow StreetLiverpoolUKL69 3GL
| | - Carmel P Noonan
- Aintree University Hospitals NHS Foundation TrustDepartment of OphthalmologyLower LaneLiverpoolUKL9 7AL
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Medial rectus muscle elongation, a technique to treat very large-angle esotropia. Graefes Arch Clin Exp Ophthalmol 2015; 253:1005-11. [PMID: 25845955 DOI: 10.1007/s00417-015-2992-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 03/06/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE The purpose was to describe the medial rectus muscle elongation (MRE) procedure to treat very large-angle esotropia (ET) with surgery on a lower number of muscles. METHODS Twenty patients with very large-angle ET (more than 70 PD) underwent the MRE procedure. In the MRE procedure, the muscle was split longitudinally into three parts. The wider central part was sutured with 6/0 vicryl and disinserted. The distal end of the peripheral parts (still attached to the original insertion), 7-9 mm away from the insertion, was sutured to the proximal end of the central part. At the end of the procedure, the distance of the anastomosis site from the insertion was named as the final elongation. The dose-response effect of the final elongation was calculated in bilateral MRE cases. The mean of the dose-response effect, obtained in the binocular surgery group, was used in the monocular surgery group to calculate the resection effect of lateral rectus (LR) muscle. RESULTS Eleven patients underwent bilateral MRE and nine patients underwent unilateral MRE and LR muscle resection. The mean preoperative far and near deviation was 94.10 ± 19.33 PD. The mean postoperative deviation was 14.60 ± 18.07 PD for far and 14.50 ± 18.23 PD for near deviation. In bilateral MRE cases, the mean dose-response effect of the elongation was 5.53 ± 0.67 PD/mm for far and 5.58 ± 0.69 PD/mm for near deviation. The mean LR muscle resection effect was 6.41 ± 1.99 PD/mm for far and 6.28 ± 1.93 PD/mm for near deviation. CONCLUSION The MRE procedure seems an acceptable method to treat very large-angle ET with surgery on a lower number of muscles.
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Kassem IS, Miller MT, Archer SM. One Year of Pediatric Ophthalmology and Strabismus Research in Review. Asia Pac J Ophthalmol (Phila) 2013; 2:388-400. [PMID: 26107151 PMCID: PMC6839686 DOI: 10.1097/apo.0000000000000019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To highlight recent advances in amblyopia and strabismus. DESIGN Literature review. METHODS A literature search of articles published in the English language was performed in PubMed or MEDLINE between May 2012 and April 2013 using the terms amblyopia or strabismus. Articles deemed relevant were selected. RESULTS The review highlights articles that increase our understanding of strabismus and amblyopia as well as newer treatment strategies. CONCLUSIONS The review highlights some new information and possible future advances in amblyopia and strabismus.
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Affiliation(s)
- Iris S Kassem
- From the *University of Illinois at Chicago Eye and Ear Infirmary, Chicago, IL; and †Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, MI
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Bittencourt MKW, de Vasconcellos JPC, Bittencourt MD, Malagó R, Bacellar M. Evaluation of the Efficacy and Safety of Botulinum Toxin Type A to Induce Temporary Ptosis in Dogs. J Ocul Pharmacol Ther 2013; 29:431-6. [DOI: 10.1089/jop.2012.0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Rodolfo Malagó
- Department of Veterinary Clinical Medicine, Itajubá Veterinary College (FEPI), Itajubá, Minas Gerais, Brazil
| | - Marianna Bacellar
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
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