Use of botulinum toxin in small-angle heterotropia and decompensating heterophoria: a review of the literature.

Botulinum toxin has been used extensively in strabismus management. However, less is published regarding its use in small-angled manifest deviations or decompensating heterophorias, where an alternative to surgery is required. The aim of this review is to look at the use and effectiveness of botulinum toxin in managing small-angled manifest deviations, both constant and intermittent, and decompensating heterophorias. These types of strabismus can prove difficult to manage, as the angle present is often too small for surgery to be advised, but it may still cause a cosmetic or symptom-producing problem. A search of the English speaking literature was undertaken using Medline facilities as well as a limited manual search of non-Medline journals and transactions. A brief overview is provided for mechanisms of action, complications and dose effects, and diagnostic and therapeutic uses of botulinum toxin. The main reported complications are those of ptosis, induced vertical deviation and subconjunctival haemorrhage. The higher the dose, the greater the risk of complications. In small-angle strabismus, botulinum toxin is reported as particularly useful in cases of acquired and acute-onset esotropia in aiding maintenance of binocular vision. It is useful for additional management of surgically under- or over-corrected esotropia, particularly for those with potential for binocular vision. Less effect is reported in primary exotropia versus primary esotropia. It is the management of choice for consecutive exotropia, particularly when patients have had previous multiple surgery and where there is a risk for postoperative diplopia. Botulinum toxin has a specific role in decompensated heterophoria, allowing the visual axes a chance to 'lock on' and subsequently maintain binocular vision. Successful outcomes are reported after 1-2 injections only but the results are best in cases of heterophoria with little near-distance angle disparity.