Kowal L, Marshman W, Sahare P1 Botox Audit 40 cases ≥3mo follow up Retrospective private practice...
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Transcript of Kowal L, Marshman W, Sahare P1 Botox Audit 40 cases ≥3mo follow up Retrospective private practice...
Kowal L, Marshman W, Sahare P 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 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
Kowal L, Marshman W, Sahare P 12
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
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 randomisationLow % 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