Vitreous hemorrhage and Rhegmatogenous retinal detachment that developed after botulinum toxin injection to the extraocular muscle: case report

Abstract

BackgroundThe authors report a case of a rare complication that occurred after botulinum toxin injection to the extraocular muscle, which was easily overlooked and successfully corrected by surgery.Case presentationA 34-year-old female patient visited our clinic for diplopia and ocular motility disorder after removal of an epidermoid tumor of the brain. At her initial visit, her best-corrected visual acuity (BCVA) was 20/20 for both eyes. An alternate cover test showed 45 prism-diopter esotropia and 3 prism-diopter hypertropia in the right eye. Following 6 months of observation, the deviation of the strabismus did not improve, and botulinum toxin was injected into the right medial rectus (RMR). After 6 days, she visited our clinic with decreased visual acuity of her right eye. The BCVA was found to be 20/50 for her right eye. Funduscopic examination presented a retinal tear inferonasal to the optic disc with preretinal hemorrhage. Subretinal fluid nasal to the fovea was seen on optical coherence tomography (OCT). Barrier laser photocoagulation was done around the retinal tear; however, her visual acuity continued to decrease, and vitreous hemorrhage and subretinal fluid at the lesion did not improve. In addition, a newly developed epiretinal membrane was seen on OCT. An alternate cover test presented 30 prism-diopter right esotropia. 19 weeks after RMR botulinum toxin injection, she received pars plana vitrectomy, membranectomy, endolaser barrier photocoagulation, and intravitreal bevacizumab (Avastin®) injection. After 4 months, her visual acuity improved to 20/20, and only 4 prism-diopter of right hypertropia and 3 prism-diopter of exotropia were noted. Vitreous opacity and the epiretinal membrane were completely removed, as confirmed by funduscopic and examination.ConclusionsSudden loss of vision after injection of botulinum toxin into the extraocular muscle may suggest a serious complication, and a prompt, thorough ophthalmic examination should be performed. If improvements are not observed, rapid surgical intervention is recommended to prevent additional complications.Electronic supplementary materialThe online version of this article (10.1186/s12886-017-0649-2) contains supplementary material, which is available to authorized users.

Botulinum toxin injection without electromyographic guidance in consecutive esotropia

“…Scleral perforation has only been reported in two cases after botulinum toxin injection without electromyographic guidance [ 24 , 25 ]. This is also extremely rare after botulinum toxin injection with electromyographic guidance [ 26 , 27 ], with an incidence of 0.002% [ 15 ]. In rabbits, Paik et al [ 28 ] found no different morphologic changes in the extraocular muscle fiber layers between direct intramuscular injection and subtenon injection of botulinum toxin.…”

Cilioretinal artery occlusion and anterior ischaemic optic neuropathy due to periocular botulinum toxin a injection: A case report

“…Some transient ocular complications, such as ptosis, diplopia and glaucoma, have been reported due to periocular and extraocular BTA injection 3 . Rarely, vitreous haemorrhage and restrictive optic neuropathy have also been described 3,4 .…”

“…Some transient ocular complications, such as ptosis, diplopia and glaucoma, have been reported due to periocular and extraocular BTA injection 3 . Rarely, vitreous haemorrhage and restrictive optic neuropathy have also been described 3,4 . Only one study has shown that transient vision loss due to retinal ischaemia may occur after cosmetic BTA injection in the masseter muscle 5 .…”

The whole truth about botulinum toxin – a review

“…Periorbital botulinum toxin injection can cause mydriasis of the pupil, resulting in acute angle closure attack. Cases have been reported in which the botulinum toxin was improperly injected into the vitreous cavity of a patient receiving treatment to the right medial rectus, resulting in increased intraocular pressure, decreased visual acuity and retinal detachment [ 18 ]. Apart from periorbital complications, other aesthetic side effects associated with botulinum toxin injection for forehead horizontal lines are the exaggeration of wrinkles, brow ptosis, “Mephisto sign”, and periorbital edema.…”