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Case Reports
. 2009 Dec:107:104-9.

Treating strabismus by injecting the agonist muscle with bupivacaine and the antagonist with botulinum toxin

Alan B Scott  1 , Joel M Miller, Kevin R Shieh
Affiliations
Case Reports

Treating strabismus by injecting the agonist muscle with bupivacaine and the antagonist with botulinum toxin

Alan B Scott et al. Trans Am Ophthalmol Soc. 2009 Dec.

Abstract

Purpose: We report the results of injection of bupivacaine (BUP) and botulinum toxin (BT) into agonist and antagonist muscles, respectively, to treat horizontal strabismus.

Methods: We treated both horizontal muscles of 7 patients with comitant horizontal strabismus, 2 patients with partial lateral rectus (LR) paralysis, and one elderly myopic patient with acquired esotropia, injecting the agonist muscle with BUP in concentrations of 0.75% to 3.0% and volumes of 3.0 to 5.0 mL, and the antagonist with BT in about half the usual therapeutic dose to prevent it from stretching the BUP-treated muscle during its regeneration following BUP myotoxicity. We reinjected BT in one patient who had an inadequate response from the initial BT dose.

Results: The 7 comitant patients were corrected (on average) 19.7 prism diopters (Delta), from 28.3Delta to 8.6Delta, at 193 days after injection. Muscle volume increase after BUP injection was 5.8% at 158 days. One LR palsy patient without LR atrophy was changed 55Delta; the other, with LR atrophy, was corrected 4Delta. Two patients had transient vertical deviations from the BT injection. The myopic patient with esotropia was unchanged.

Conclusions: Injections of BUP and BT corrected 7 patients with comitant horizontal strabismus an average of 19.7Delta, about double the correction reported from BUP injection alone. BUP-injected muscles increased size by 5.8%. Of 2 patients with LR weakness, one without LR atrophy was changed by 55Delta, but another with LR atrophy was corrected only 4Delta.

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Figures

FIGURE 1
FIGURE 1
Changes in deviation over time in 7 patients injected with bupivacaine and botulinum toxin. PD, prism diopters.
FIGURE 2
FIGURE 2
Changes in the size of the muscles injected with bupivacaine.
FIGURE 3
FIGURE 3
Changes in the size of the muscles injected with botulinum toxin.
FIGURE 4
FIGURE 4
Case 3. Top row, Preinjection, 16Δ exotropia. Second row, 30 minutes after injection, with paralysis of the left medial rectus (LMR). Third row, 13 days after injection, 16Δ exotropia, with paralysis of both the LMR and left lateral rectus. Bottom row, 355 days after injection, eyes are straight.
FIGURE 5
FIGURE 5
Case 2. Eye rotations 88 days after injection. Bottom photo of patient during right gaze shows retraction and exotropia.
FIGURE 6
FIGURE 6
Case 2. Magnetic resonance coronal plane image 88 days after injection, showing local enlargement of right lateral rectus injected with bupivacaine..
FIGURE 7
FIGURE 7
Case 6. Top, Before injection, the left eye is still healing from prior surgery. Bottom, 160 days after injection, the eyes are straight.
See this image and copyright information in PMC

References

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    1. Hill M, Wernig A, Goldspink G. Muscle satellite cell activation during local tissue injury and repair. J Anat. 2003;203:89–99. - PMC - PubMed
    1. Anderson BC, Christiansen SP, Grandt S, Grange RW, McLoon LK. Increased extraocular muscle strength with direct injection of insulin-like growth factor-I. Invest Ophthalmol Vis Sci. 2006;47:2461–2467. - PMC - PubMed
    1. Scott AB, Miller JM, Shieh KR. Bupivacaine injection of the lateral rectus muscle to treat esotropia. J AAPOS. 2009;13:119–122. - PubMed

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