Strabismus

ISSN: 0927-3972 (Print) 1744-5132 (Online) Journal homepage: http://www.tandfonline.com/loi/istr20

Botulinum toxin as a tool for testing the risk of

postoperative diplopia

Zita Nüssgens & Peter Roggenkämper

To cite this article: Zita Nüssgens & Peter Roggenkämper (1993) Botulinum toxin as a tool for
testing the risk of postoperative diplopia, Strabismus, 1:4, 181-186

To link to this article: http://dx.doi.org/10.3109/09273979309052369

Published online: 08 Jul 2009.

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 0 Aeolus Press
Strabismus 0927-3972/93/US$ 3.50 (Accepted 30 September 1993)

Botulinum toxin as a tool for testing the risk of

postoperative diplopia
ZITA NUSSGENS and PETER ROGGENKAMPER

Universitats-Augenklinik, Sigmund-Freud Strasse 25, 0-53105 Bonn, Germany

ABSTRACT. If preoperative examinations indicate postoperative diplopia, we generally would

dissuade a patient from a squint operation. In this situation, a reliable test for diplopia can be
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done by injection of Botulinum toxin into an eye-muscle. Thus a predominantly transient paresis
is produced during which there is parallelism for a sufficient period of time, so that the patient
has time enough to experience disturbing double vision or its absence. In all 31 patients of this
study a clear decision for or against an operationwas possible, only in three cases was an operation
contraindicated.
Key words: Botulinum toxin; risk of postoperative diplopia; postoperative diplopia

INTRODUCTION squint (over weeks) produced by Botulinum

If preoperative examinations (performed by
prism compensation of the angle of squint and
forced-duction test) indicate the probability of
postoperative diplopia, we generally would dis-
suade a patient from a squint operation because
of possible intractable diplopia which would be
distressing and unbearable for the patient; in-
tractable diplopia may persist despite treatment
with prisms, orthoptic training or surgery'. Pa-
tients are often very unhappy about this advice
and suffer from their squint. Diplopia may oc-
cur also after squint surgery, more likely in ex-
otropia than in esophoria2y3.Therapy of persis-
tent diplopia is known to be an ungrateful task;
in the majority of cases, partial occlusion (with
an occlusion glass or an opaque glass) is the only
therapy, but is unpopular with most patients4.
In this study, we tried to find out whether the
predominantly transient change of angle of
toxin injections in an eye muscle, can help to de-
cide for an operation in patients at risk. In an
earlier publication we reported on the first at-
tempt using Botulinum toxin in evaluation of
postoperative diplopia with already positive re-
s u l t ~ In
~ ~the
. same year an English paper re-
ported on the predictive value of Botulinum
toxin to evaluate the sensory state6.
At the end of the seventies, A.B. Scott (Smith-
Kettlewell Institute of Visual Sciences, San
Francisco, U.S.A.) reported on Botulinum
toxin as a substance suitable for treatment of
strabismus7. In later years many indications for
the use of this drug were found, especially (be-
sides a number of types of strabismus) the treat-
ment of blepharo~pasm~**-'~.
According to our experience, in eye motility
disorders Botulinum toxin has been especially
valuable in cases of
- endocrine myopathy

Strabismus - 1993, Vol. 1, No. 4, pp. 181-186 181

0 Aeolus Press Buren (The Netherlands) 1993
 Z . Niissgens and P. Roggenkarnper

TABLE 1. Patient characteristics in the convergent group

Pat.No. sex age type of strabismus previous eye-surgery

38 m 63 since 1 0 y., unknown etiology none

50 f 25 congenital 2 squint operations

52 f 33 congenital 1 squint operation

71 f 23 congenital 1 squint operation

72 rn 32 congenital none
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79 m 33 congenital none

83 f 33 consecutive 1 squint operation

111 f 29 decornpensated rnicrotropia none

114 m 19 congenital none

132 m 19 congenital none

151 f 26 congenital none

183 f 21 since 3 y., unknown etiology 1 squint operation

184 m 16 since 3 y . , unknown etiology none

187 f 20 congenital none

- small convergent angle of squint MATERIALS AND METHODS

- paresis of recent onset
- contraindication of operation
- only relative indication for an operation
and some special indications such as con-
vergence spasm.
By injection of Botulinum toxin a predomi-
nantly transient alteration of the angle is pro-
duced during which there is parallelism for a
sufficient period of time, so that the patient has
time enough to experience disturbing double
vision or its absence.
Thirty-one patients received Botulinum trea
ment in order to evaluate postoperative diplopi
(16 females (51.6%), 15 males (48.4Vo)); 14 p;
tients suffered from convergent strabismus an
17 patients from divergent strabismus (for di
tails see Tables 1 and 2). Four patients receive
two injections, one patient three, so we injecte
37 times in total. In the convergent group 17 ii
jections were given, in the divergent group 20 ii
jections. The mean age in all patients was 30.4

182
 Botulinum toxin test for postoperative diplopia

TABLE 2. Patient characteristics in the divergent group

Pat.No. sex age type of strabismus previous eye-surgery remarks

41 f 56 consecutive 1 squint operation

67 m 39 consecutive 2 squint operatic

74 m 31 secondary none coloborna of choroid

97 f 36 secondary none aphakia OD

109 rn 20 consecutive 1 squint operation

113 f 26 congenital (consecutive?) 1 squint operation

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122 m 25 consecutive 1 squint operation

124 m 23 secondary 2 squint operations aphakia OD

142 m 28 consecutive 1 squint operation

154 f 23 consecutive 3 squint operations

156 f 59 secondary none condition after trauma

(coma for 3 weeks)
159 f 16 consecutive 2 squint operations

162 m 19 congenital none

169 rn 29 consecutive 2 squint operations

171 rn 27 residual divergent squint 1 squint operation congenital lllrd and

lVth nerve palsy
174 f 41 congenital none

189 f 51 consecutive 1 squint operation

(s= 12.4), in the convergent group 28.0 y
(s = 11.7), and in the divergent group the mean
age was 32.3 y ( s = 12.9).
Prior to injection the patient was prepared
by several drops of topic anesthetic (Proxy-
metacain) for about ten minutes. We used
BOTOX@ (Botulinum Toxin Type A, formerly
Oculinum@)*. The dose of BOTOX@ injected
per muscle varied - depending on the angle of
* Allergan Pharmaceuticals (a Divsion of Allergan,
Inc., Irvine, CA 92713, U.S.A)
squint - between 0.05 ml (= 1.25 U) and 0.1 ml
( = 2.5 U). Injection was performed using an
electromyographic injection needle (1 ?h” , 27
gauge needle) attached to a 1.0 ml tuberculin
syringe. DISA EMG-equipment was used for
visual and auditory presentation of the signals
during injection.
After injection all patients underwent fundus-
copy to ensure that there was no damage of the
eyeball.

183
 Z.Niissgens and P. Roggenkamper

TABLE 3. Reduction of angIe of squint

Ang L e perat ion ore thar 10operation side effects

before injection tanned or inject. double
of BOTOX erformed vision) tosis ert ical
(cm/m) evi a t i01

+ 60 X
+ 30 X
+ 30 X X
+ 8 X
+ 10 X
+ 60 X
+ 15 X
+ 45 X
+ 30 X
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+ 20 X
+ 2s X
+ 30 X
+ 25 X
+ 30 X

- 35 X
- 20 X
- 14 X X
- 18 X
- 45 X
- 55
- 50 X
- 5s
- 50 X
- 35 X
- 60 X
- 30 X X
- 35 X
- 45 X
- 45 X
- 40 X
- 35

RESULTS days. For instance, a convergent squint will the

All 31 patients could be reexamined after treat-
ment. Depending on the widely varying angle of
deviation before injection, the results varied
from one patient to another.
The effect on the reduction of the angle of
squint is shown in Table 3. After direct in-
tramuscular injection of Botulinum toxin a mus-
cle lengthening effect starts a few days later and
a maximum will be reached after around ten
be changed into a divergent one, but with th
smooth reduction of the paretic effect, withi
weeks we can expect a certain time of alignmer
during which the patient observes either doubl
vision or not. Alignment occurred in all of OL
cases, with exception of five patients with Boti
linum toxin induced vertical deviation as a sic
effect (vertical divergence of more than
cm/m). In these five patients however, either b
a special head position (two patients) or by tf

184

use of vertical prisms (three patients) the ques-
tion of double vision could be answered. From
the latter three patients a second injection was
performed in one case, this time without vertical
deviation.
The 14 patients in the group of the convergent
squinters showed angles of very different sizes,
but all reported (horizontal) orthotropia at a cer-
tain time after injection, and on reexamination
(two to four months later) they still demon-
strated a distinctly smaller angle when compared
with the angle before treatment. No patient no-
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ticed disturbing double vision. Thus there was
no objection against squint operation in all cases
of esotropia. In this group, 17 injections were
performed, three patients (Nos. 72, 111, 183)
received two injections; they changed their mind
concerning an operation and wished to be
treated with Botulinum toxin only.
In the group of the I7 divergent squinters, 20
injections were given. One patient (No. 67) had
had three squint operations before and he
wished to receive only Botulinum toxin treat-
ment, and another patient (No. 109) did not
show any effect after the first treatment and was
injected a second time (which was effective). In
three cases (Nos. 113, 124,and 189)the patients
reported a disturbing double vision during the
time of the effect of the injection. In these cases,
we considered an operation as contraindicated.
In all 31 patients of this study, a clear decision
for or against an operation was possible. Only in
three cases (i.e., approximately every tenth pa-
tient) was an operation contraindicated. In the
meantime - due to a long waiting list - only ten
of them have been operated. The absence of
double vision has been proven postoperativelyin
these cases.
Side effects could be observed in eight cases:
ptosis (n = 3), which in none of the cases oc-
cluded the eye completely, and - as mentioned
Botulinum toxin test for postoperative diplopia
- vertical deviation (n = 5). These findings can
be explained by diffusion of Botulinum toxin
into adjacent muscles. These side effects are
well known from other studiesl1-l3. Transient
blurred vision was found in one case. The last
complication is uncommon with this treatment
and the patient's observation cannot be ex-
plained retrospectively. Severe complications
did not occur.
DISCUSSION
In all patients injected, we could make a decision
whether an operation would be indicated or not.
In 28 out of the 31 patients, the results showed
no disturbing double vision during the time of
approximate orthotropia. So only three cases
(approx. 10%) (interestingly only divergent
squint was concerned) had a high risk of post-
operative diplopia and were dissuaded from an
operation.
In the literature, we only found two papers
from Moorfields Eye Hospital, London6-'*and
a summary from the International Orthoptic
Congress in Nurnberg in 199114 dealing with
this subject. Watkins and Lee's study in 1991
described surgery as contra-indicated in 15 pa-
tients out of 45 (33.3V0)~.Possibly this different
percentage results from a different patient popu-
lation and the all in all small number of patients
in the studies.
Botulinum toxin intramuscular injection for
diagnostic purposes seems to be a safe method
for this indication. In no case could a severe side
effect be seen; only temporary complications
such as ptosis and vertical deviation could be ob-
served. In the literature severe problems are
described as extremely rare. Of 7,602 strabismus
injections, nine eyes were perforated by injec-
tion needles and in 15 cases a retrobulbar hemor-
rhage could be observed, but none of these pa-
tients lost vision".
185
 Z. Niissgens and P. Roggenkamper

As an alternative to Botulinum toxin injec-
tions the prism adaptation test should be consid-
ered of course. But just in those cases presented
in our study, the prism test revealed permanent
diplopia. Moreover, it is well known that in
some cases prism adaptation does not predict the
real postoperative The forced-duction
test also showed permanent diplopia in all cases.
Finally, the above mentioned possible compli-
cations after Botulinum toxin injections (ptosis,
vertical deviation) would be avoidable if surgical
therapy is performed. It is known that highly
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risk of postoperative diplopia; and the patieni
were operated back if the diplopia really turne
out to be permanent. But we think that Botul
num toxin treatment is much less uncomfortabl
and radical for the patient than two surgical ir
terventions. There is even no guarantee of coxr
plete lack of double vision'.
In conclusion, if testing with prism compensz
tion and/or forced-duction test would predic
postoperative diplopia, we consider the Botul
num toxin injection to be a valuable tool for th
final solution of the question of postoperativ

motivated patients were operated in spite of the diplopia.

REFERENCES

1. Gruzensky WD, Palmer EA. Intractable diplopia: a clinical perspective. Graefe's Arch Clin Exp Ophtha
mol 1988; 226: 187-192.
2. Haase W, Ehlers P, Sautter H. Die Diplopie-Haufigkeit im Rahmen der operativen Behandlung des Beglei
schielens. Klin Mbl Augenheilk 1979; 175: 375-384.
3. Todter F. Diplopie nach Schieloperationen bei Erwachsenen. Klin Mbl Augenheilk 1981; 179: 496-50(
4. Crone RA. Persistent diplopia in cases of concomitant squint. In: Crone RA: Diplopia. Amsterdam: EJ
cerpta Medica, 1979; 187-206.
5. Roggenkamper P. Blepharospasmus-Behandlungmit Botulinus-Toxin (Verlaufsbeobachtungen). Klin Mt
Augenheilk 1986; 189: 283-285.
6. Watkins SE, Lee JP. The pre-operative predictive value of Botulinum toxin A. In: Transactions of the 7t
Int Orthoptic Congress, Niirnberg, 1991; 189-193.
7. Scott AB. An alternative to strabismus surgery. In: Transactions of the 4th Int Orthoptic Congress, Berm
1979; 42-45.
8. Roggenkamper P, Rothe R. Indikationen zur Botulinus-Toxin-Injektion. Z Prakt Augenheilk 1988; S
282-284.
9. Scott AB. Botulinum toxin injection of eye muscles to correct strabismus. Trans Am Ophthalmol SOC1981
7 9 734-770.
10. Scott AB, Kennedy RA, Stubbs HA. Botulinum A toxin injection as a treatment for blepharospasm. Arc
Ophthalmol 1985; 103: 347-350.
11. American Academy of Ophthalmology. Botulinum toxin therapy of eye muscle disorders. Ophthalmolog
(part 2, Instrument) 1989; 37-41.
12. Powell C, Ketley J, Lee J, Elston J. Botulinum toxin adaptation test: Use of Botulinum toxin in the investj
gation of the sensory state in strabismus. In: Transactions of the 6th Int Orthoptic Congress, Harrogatc
1987; p 101.
13. Roggenkarnper P, NiiBgens Z. Botulinis-Toxin-Injektionals Test bei Gefahr postoperativer Diplopie.
Prakt Augenheilk 1991; 12: 301-303.
14. Davis H. Risk of postoperative diplopia - can B.T. help? In: Final Programme of the VII Internations
Orthoptic Congress, Nurnberg, 2-6 June, 1991; p 178.
15. De Decker W. Persistierende Diplopie beim Begleitschielen. Augeniirztl Fortbildg 1982; 7: 317-355.

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