Comparison of Dose Increments of Botulinum Toxin A with Surgery as Primary Treatment for Infantile Esotropia and Partially Accommodative Esotropia

PURPOSE: To compare the effect of increment dose of botulinum toxin (BTX) injection in correlation to the angle of deviation to bilateral medial rectus recession (BMR) in infantile esotropia and partially accommodative esotropia (PAET). METHODS: This was a retrospective study that included pediatric patients ≤16 years old with infantile esotropia and PAET at Dhahran Eye Specialist Hospital (DESH) from 2014 till 2021 treated with increment dose of BTX or BMR. A successful outcome is defined as ocular alignment within 10 PD of deviation after 1–3 BTX injections or one surgery with a minimum follow-up of 6 months. RESULTS: Of 177 patients, 101 patients received BTX treatment for either infantile esotropia (n = 37) or PAET (n = 64) and 76 patients underwent BMR for either infantile ET (n = 25) or PAET (n = 51). BTX showed a higher success rate than BMR {65.3% vs 55.3% (p = 0.174)}. In patients with infantile esotropia, the success rate was comparable between BTX group and BMR group {40.5% vs 52% (p = 0.440)}. However, the success rate was statistically significantly higher in BTX group in compare to BMR group {79.7% vs 56.9% (p = 0.014)}. Consecutive exotropia was 0% in BTX group and 9.2% in BMR group (p = 0.002). CONCLUSION: The increment dose of BTX injection is comparable to surgery in patients with infantile esotropia but superior to the routine surgery in patients with PAET. BTX has the advantage of a shorter procedure duration, lower costs, less exposure to general anesthesia and being minimally invasive intervention.