Botulinum Toxin as an Alternative to Treat the Spasm of the Near Reflex

We describe the case of an eight-year-old girl with complaints of headaches and blurred vision (uncorrected visual acuity: 0.1 decimal) that showed on examination miotic pupils, pseudomyopia, no ocular motility restrictions, and no associated neurological disease. After initial treatment with cyclopentolate for two months, pseudomyopia persisted with an intermittent and variable esotropia. Spectacles of +1 both eyes and atropine 1% one drop daily were then prescribed. The situation improved and remained stable for several weeks, with pseudomyopia and esotropia reappearing later. Finally, botulinum toxin (2.5 iu Botox®) was injected in the medial rectus muscle on two occasions and a visual therapy program based on the stimulation of fusional divergence, diplopia, and stereopsis consciousness was recommended. This prescription was combined with the use of atropine during the first few weeks. Orthotropia and corrected distance visual acuity of 1.0 were found three months after treatment. The evolution and clinical results of this case report suggest that botulinum toxin in combination with other therapeutic alternatives may be useful in the treatment of spasm of the near reflex.

Evaluation of Binocular Vision Therapy Efficacy by 3D Video-Oculography Measurement of Binocular Alignment and Motility

Objective: To evaluate two cases of intermittent exotropia (IX(T)) treated by vision therapy the efficacy of the treatment by complementing the clinical examination with a 3-D video-oculography to register and to evidence the potential applicability of this technology for such purpose. Methods: We report the binocular alignment changes occurring after vision therapy in a woman of 36 years with an IX(T) of 25 prism diopters (Δ) at far and 18 Δ at near and a child of 10 years with 8 Δ of IX(T) in primary position associated to 6 Δ of left eye hypotropia. Both patients presented good visual acuity with correction in both eyes. Instability of ocular deviation was evident by VOG analysis, revealing also the presence of vertical and torsional components. Binocular vision therapy was prescribed and performed including different types of vergence, accommodation, and consciousness of diplopia training. Results: After therapy, excellent ranges of fusional vergence and a “to-the-nose” near point of convergence were obtained. The 3-D VOG examination (Sensoro Motoric Instruments, Teltow, Germany) confirmed the compensation of the deviation with a high level of stability of binocular alignment. Significant improvement could be observed after therapy in the vertical and torsional components that were found to become more stable. Patients were very satisfied with the outcome obtained by vision therapy. Conclusion: 3D-VOG is a useful technique for providing an objective register of the compensation of the ocular deviation and the stability of the binocular alignment achieved after vision therapy in cases of IX(T), providing a detailed analysis of vertical and torsional improvements.