Conventional surgery versus botulinum toxin injections for partially accommodative esotropia.

[PURPOSE] To compare the effect of botulinum toxin injection (BTX) to bilateral medial rectus recession (BMR) in partially accommodative esotropia (PAET).

[METHODS] The medical records of children 1-14 years of age treated for PAET with BMR or BTX between 2010 and 2020 at a single institution were reviewed retrospectively. PAET was defined as residual esotropia of at least 14 after 6 weeks of continuous wear of full cycloplegic refraction (> +2.5 D). Success was defined as esotropia of 0-10 after a single surgery or ≥1 BTX injections.

[RESULTS] Of 224 patients, 121 received BTX and 103 underwent BMR. BMR showed a higher success rate than BTX (70.9% vs 53.7% [P = 0.006]). BMR was more successful in males, in patients >5 years of age, and when spherical equivalent was ≤ +5.00 D (79.2%, 74.3%, and 67.5%, resp. [P < 0.05]). Mean follow-up was shorter in the BMR group than in the BTX group (16.7 ± 14.7 vs 31.4 ± 29.5 months [P = 0.0001]). Mean duration of surgery was significantly shorter in the BTX group (5.2 ± 4.3 vs 70.5 ± 31.4 min [P = 0.0001]). Postoperative inferior oblique overaction was more common in the BTX group (7.4%; P = 0.02 [Fisher exact test]), and persistent ptosis was only seen in the BTX group (0.8%); consecutive exotropia was only seen in the BMR group (2%).

[CONCLUSIONS] In our study cohort, BMR had a higher success rate than BTX. Conventional surgery allowed for shorter follow-up and fewer complications than BTX in the treatment of PAET.