Brachial plexopathy after Botulinum toxin administration for cervical dystonia.The use of Botulinum toxin (BT) for the treatment of cervical dystonia is considered safe and effective."2 The existence of two preparations on the market justifies reporting not only the positive results but also the possible adverse reactions so that the best one can be selected for clinical practice.Brachial plexopathy was once reported following cervical injection of BT.3 This occurred with the USA preparation (Oculinum) and was never mentioned with the UK preparation (Dysport).A 32 year old housewife complained of involuntary movements of the neck for one month. There was no family history of involuntary movements. At age 29, dizziness and vertigo had been treated for some weeks with triethylperazine and Cinnarizine.Right laterotorsion and retropulsion of the head was accompanied by pain and contracture of the posterior cervical muscles. Neurological examination was otherwise normal. The severity of this cervical dystonia was scored as 9 according to the Tsui rating scale (maximum 25).4Laboratory investigations, including cervical NMR, were negative.The patient was treated according to our current protocol with BT (Dysport). Two points in the right sternomastoid and 3 points in each side of the posterior cervical region (trapezius and splenium capitis) were each injected with 100 U, total amount 800 U.There was no clinical benefit on the following days. On the sixth day, however, she complained of increasing neck pain irradiating to the left upper limb. There were also tongue sores and a certain degree of lip oedema, which were only evaluated retrospectively. A second administration of BT was then considered. Two weeks after the first treatment she was injected with a total dose of 400 U of BT distributed between 4 points (two in each side) on the posterior cervical region.Fifteen days after this second administration of BT, she complained of weakness of the right upper limb. Pain was still present on the neck and on the left arm. Neurological examination, at this time, revealed decreased muscular strength (3/5) of right supraspinatus, deltoid and biceps; the right biceps reflex was absent and brachioradialis reflex inverted; on the left side there were no signs of neurological dysfunction except for the pain as mentioned above. Electromyography on the right deltoid and biceps showed fibrillations and positive sharps waves at rest, and reduced interference pattern on maximal contraction with pathological polyphasic (normal amplitude and duration) potentials. Right brachial plexus stimulation evoked normal motor responses on the deltoid. Median nerves F waves were normal. Somatosensory evoked potentials (SEP) were normal for median and ulnar nerves bilaterally. SEP of the radial nerves had normal plexus evoked responses, absent cervical (C2) waves and cortical waves were present on both sides with central conduction times at normal limits.These electrophysiological studies were consistent with C5-C6 upper trunk plexopathy exclusiv...

A new technique for the treatment of diplopia secondary to cosmetic botulinum to xin A use is described. In this interventional case reports, two consecutive patients who developed diplopia after periocular cosmetic use of botulinum toxin A were treated with intramuscular botulinum toxin A injection into the antagonist ex traocular muscle. Diplopia resolved in both patients in less than 1 week with no side effects or complications. In conclusion, the injection of intramuscular botulinum toxin A is an encouraging option for treatment of diplopia secondary to botulinum toxin A use for facial lifting.

Objetivo: Investigar a associação da hipermetropia com ambliopia, estrabismo, anisometropia e astigmatismo. Métodos: A hiperopia foi classificada em Grupo 1: maior ou igual a +5.00D; Grupo 2: maior que +3.25D e menor que +5.00D, com diferença de equivalente esférico maior ou igual a 0.50D; Grupo 3: maior que +3.25D e menor que +5.00D, com diferença de equivalente esférico menor que 0.50D e Grupo 4: com equivalente esférico maior e igual a +2.00D. O Grupo controle pertencente ao equivalente esférico menor que +2.00D. Resultados: A presença de hipermetropia maior e igual a SE+2.00D foi significativamente associada à maior proporção de crianças com ambliopia (27,2 vs. 14,8%, OR = 2,150, p<0,001) e estrabismo (70,8 vs. 39,3%, OR = 3,758, p<0,0001. A presença de hipermetropia também foi significativamente associada à maior proporção de anisometropia nos grupos com hipermetropia maior e igual a SE+2.00 (29,1 vs. 9,9%, OR = 3,708, p<0,0001) e astigmatismo (24 vs. 9,9%, OR = 2,859 p<0,0001). Conclusão: A presença e magnitude da hipermetropia entre crianças foram associadas à maior proporção de erros refrativos e visuais, como estrabismo, ambliopia, astigmatismo e anisometropia.