Journal of Ophthalmic and Vision Research

Published date: Jul 31 2025

Journal Title: Journal of Ophthalmic and Vision Research

Issue title: ‎Volume 20 - 2025

Pages: 1 - 8

DOI: 10.18502/jovr.v20.14661

Ying Wangwying1010@126.comDepartment of Ophthalmology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing

Jingjing Jiangjiangjingjing@mail.ccmu.edu.cnDepartment of Ophthalmology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing

Li Lilili@bch.com.cnDepartment of Ophthalmology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing

Purpose: To evaluate and compare the clinical features and efficacy of botulinum toxin A (BTX-A) injection versus surgery in acute-onset concomitant esotropia (ACE) in children.
Methods: This retrospective comparative clinical study was conducted on 40 children with ACE. The patients were assigned to either the surgery group (n = 23) or the BTX-A group (n = 17). Successful motor outcomes were defined as residual esodeviation of <5 prism diopters (PD), while successful sensory outcomes were defined as the presence of any evidence of sensory fusion or stereopsis.
Results: The average treatment age in this study was 7.02 ± 3.72 years in the BTX-A group and 6.41 ± 2.83 years in the surgery group. There were 5 cases of type I (12.50%), 26 cases of type II (65.00%), and 9 cases of type III (22.50%) for ACE. The deviation before treatment was +(41.35 ± 16.90) PD at near and +(39.71 ± 14.94) PD at distance in the BTX-A group. In the surgery group, the results were +(49.22 ± 18.25) PD at near and +(47.00 ± 18.53) PD at distance. After treatment, based on the measured deviation, total motor success was 95.00% (38/40) at near and 90.00% (36/40) at distance. Following treatment, 94.59% (35/37) of patients with ACE exhibited fusion, 86.84% (33/38) had near stereopsis, and 72.97% (27/37) had distance stereopsis. The motor and sensory success rates were not significantly different between the BTX-A and surgery groups. There were no statistically significant differences in motor outcomes or sensory outcomes among the three subtypes of ACE (all P > 0.05).
Conclusion: In our study, type II was the most common clinical classification for ACE. Favorable outcomes could be achieved with both BTX-A injection and surgery. There was no difference in motor or sensory outcomes regardless of clinical classification. BTX-A injection is minimally invasive, allows early intervention, and may be the preferred approach for managing ACE in children.

Keywords: Acute-onset Concomitant Esotropia, Botulinum Toxin A, Burian’s Classifications, Clinical Features, Extraocular Muscle Surgery

1. Mohney BG. Common forms of childhood strabismus in an incidence cohort. Am J Ophthalmol 2007;144:465–467.

2. Burian HM, Miller JE. Comitant convergent strabismus with acute onset. Am J Ophthalmol 1958;45:55–64.

3. Wang Y, Lang L, Zhang J, Xu L, Rong J, Guo K, et al. Efficacy of initial dose botulinum toxin A injection in acute concomitant esotropia with different clinical characteristics. Chin Med J (Engl) 2023;136:2249–2250.

4. Lee HS, Park SW, Heo H. Acute acquired comitant esotropia related to excessive Smartphone use. BMC Ophthalmol 2016;16:37.

5. Dawson E, Ali N, Lee JP. Botulinum toxin injection into the superior rectus for treatment of strabismus. Strabismus 2012;20:24–25.

6. Xu H, Sun W, Dai S, Cheng Y, Zhao J, Liu Y, et al. Botulinum toxin injection with conjunctival microincision for the treatment of acute acquired comitant esotropia and its effectiveness. J Ophthalmol 2020;2020:1702695.

7. Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev 2017;3:CD006499.

8. Dutton JJ, Fowler AM. Botulinum toxin in ophthalmology. Surv Ophthalmol 2007;52:13–31.

9. Scott AB. Botulinum toxin injection of eye muscles to correct strabismus. Trans Am Ophthalmol Soc 1981;79:734–770.

10. Binenbaum G, Chang MY, Heidary G, Morrison DG, Trivedi RH, Galvin JA, et al. Botulinum toxin injection for the treatment of strabismus: A report by the American Academy of Ophthalmology. Ophthalmology 2021;128:1766–1776.

11. Wabbels B. [Botulinum toxin - New developments in ophthalmology]. Klin Monbl Augenheilkd 2018;235:721–724.

12. Wan MJ, Gilbert A, Kazlas M, Wu C, Mantagos IS, Hunter DG, et al. The effect of botulinum toxin augmentation on strabismus surgery for large-angle infantile esotropia. Am J Ophthalmol 2018;189:160–165.

13. Bradbury JA, Taylor RH. Severe complications of strabismus surgery. J AAPOS 2013;17:59–63.

14. Escuder AG, Hunter DG. The role of botulinum toxin in the treatment of strabismus. Semin Ophthalmol 2019;34:198–204.

15. Shi M, Zhou Y, Qin A, Cheng J, Ren H. Treatment of acute acquired concomitant esotropia. BMC Ophthalmol 2021;21:9.

16. Lang LJ, Zhu Y, Li ZG, Zheng GY, Peng HY, Rong JB, et al. Comparison of botulinum toxin with surgery for the treatment of acute acquired comitant esotropia and its clinical characteristics. Sci Rep 2019;9:13869.

17. Qiongyue CJFJHjLHZ. The change in constituent ratio of acute acquired concomitant esotropia based on hospital after COVID-19 pandemic. Chinese Journal of Strabismus & Pediatric Ophthalmology 2021;29. in Chinese.

18. Chen J, Deng D, Sun Y, Shen T, Cao G, Yan J, et al. Acute acquired concomitant esotropia: Clinical features, classification, and etiology. Medicine (Baltimore) 2015;94:e2273.

19. Gisselbaek S, Hoeckele N, Klainguti G, Kaeser PF. Clinical classification of acquired concomitant esotropia. Klin Monbl Augenheilkd 2021;238:482–487.

20. Sefi-Yurdakul N. Clinical features, etiological reasons, and treatment results in patients who developed acute acquired nonaccomodative esotropia. Int Ophthalmol 2023;43:567–574.

21. Roda M, di Geronimo N, Valsecchi N, Gardini L, Fresina M, Vagge A, et al. Epidemiology, clinical features, and surgical outcomes of acute acquired concomitant esotropia associated with myopia. PLoS One 2023;18:e0280968.

22. Wan MJ, Mantagos IS, Shah AS, Kazlas M, Hunter DG. Comparison of botulinum toxin with surgery for the treatment of acute-onset comitant esotropia in children. Am J Ophthalmol 2017;176:33–39.

23. Dawson EL, Marshman WE, Adams GG. The role of botulinum toxin A in acute-onset esotropia. Ophthalmology 1999;106:1727–1730.

24. Gómez de Liaño R. The use of botulinum toxin in strabismus treatment. J Binocul Vis Ocul Motil 2019;69:51–60.

25. Mahan M, Engel JM. The resurgence of botulinum toxin injection for strabismus in children. Curr Opin Ophthalmol 2017;28:460–464.

26. Huang XQ, Hu XM, Zhao YJ, Ye MH, Yi BX, Zhou LH. Clinical efficacy of botulinum toxin type A on acute acquired comitant esotropia. Int J Ophthalmol 2022;15:1845–1851.