Management of nystagmus by surgery and botulinum toxin options: a review

Abstract

Aim: To critically evaluate the literature in order to explore the success of botulinum toxin and extraocular muscle surgery in the management of acquired nystagmus. Methods: A literature search was undertaken using the PubMed and Web of Knowledge databases. Only studies reported in English were included. Results: The aim of using botulinum toxin is to alleviate the symptoms induced by acquired nystagmus. The major problematic symptoms are oscillopsia, reduced visual acuity and abnormal head posture. An injection of botulinum toxin into the retrobulbar space is beneficial if the acquired nystagmus has horizontal, vertical and torsional components, whereas if the nystagmus is purely horizontal an injection of botulinum toxin into the horizontal rectus muscles appears to be the better option. Surgery is aimed at alleviating the symptoms induced by acquired nystagmus. Extraocular muscle surgery is of value in the management of acquired nystagmus, particularly if the patient has developed an abnormal head posture. Conclusion: It is difficult to come to any clear-cut conclusions due to the low numbers of patients that have been studied. It would, however, appear that botulinum toxin and surgery are of some value in the management of acquired nystagmus. Further research is required in this area.

The Use of Botulinum Toxin in a Case of Acquired Periodic Alternating Nystagmus

“…Surgical intervention in the form of maximal symmetrical recessions of all four horizontal rectus muscles has been reported previously with success due to the mechanical effects on the nystagmus. This procedure is designed to symmetrically weaken the horizontal rectus muscles and mechanically reduce the amplitude of the nystagmus (Bietti and Bagolini 1960;Von Noorden & Sprunger 1991;Mimura et al 2014;Hobson & Rowe 2009). However, the use of botulinum toxin is relatively new in nystagmus (as opposed to strabismus).…”

“…In nystagmus botulinum toxin is typically used for the management of strabismus (pre-op/long term) and to assess the risks of post-operative diplopia where the patient is thought to be high risk; it is a valuable adjunct to surgical treatment (Lennerstrand et al 1998). Botulinum treatment may also be used to manage a horizontal or a chin up head posture (pre-op/long term) (Hobson & Rowe 2009), or as a retrobulbar injection in acquired nystagmus (Repka, Savino & Reinecke 1994;Helveston & Pogrebniak 1988;Tomsak et al 1995). Botulinum retrobulbar toxin injection is also used in PAN (Thomas et al 1996).…”

“…In our practice (unpublished) we have also successfully used botulinum toxin for head postures, commonly recurrent head postures where horizontal rectus muscles have already been maximally recessed. It is difficult to form any definite conclusions from the literature because of the limited numbers of patients that have been reported, with different injection sites and variability in responses (Hobson and Rowe 2009). To our knowledge, this is the first published case report successfully using botulinum toxin injections into all four horizontal rectus muscles in acquired PAN.…”

“…Alternative treatments discussed were: botulinum toxin injection to all four horizontal rectus muscles to simulate the effects of surgical intervention, although not previously reported in PAN in this form (Leigh et al 1992); or maximal surgical recession of all horizontal rectus muscles, already reported effective in cases of PAN (Mimura et al 2014;Hobson & Rowe 2009). An informed decision was taken and, after discontinuation of all medications, a trial of botulinum toxin (2.5 units of Dysport Ipsen Ltd) was injected into to all four horizontal rectus muscles.…”