Bimedial rectus recession versus botulinum toxin injection for the treatment of infantile esotropia

Purpose To compare botulinum toxin injection (BTX) to the standard of care, bilateral medial rectus recession (BMR) for infantile esotropia (IET).Methods A retrospective case-control study. IET was defined as inward deviation, onset before 6 months, full motility, and no significant refractive error. We included patients from 2015 to 2023, aged 6–36 months of age, with at least 3 months of follow-up. Success was defined as esotropia 0–10 PD after one surgery or ≥ 1 BTX.Result 151 patients were included: 101 in the BTX and 50 in the BMR group. The mean age at surgery was 21.8 (±12.9) months. The preoperative angle means 40.7 (±15.5) PD in BTX and 39.5 (±10.2) in the BMR group, p = .974. The mean first dose of BTX was 6.56 ± 2.52 IU (range 5–15 IU). The success rate was 50% in the BTX group (cumulative success after up to 3 injections) and 46% in the BMR group (p = .05). The postoperative angle mean was 15.5 (±15.4) PD in BTX and 13.0 (±10.6) in the BMR group, p = .584. The BMR group had a longer postoperative follow-up (54.2 ± 20.2 vs. 32.1 ± 25.8 months, p < .001). Persistent vertical deviations were observed in 10% of the patients in the BTX group and none in the BMR group, p = .031.Conclusion Our study showed that BTX could be an alternative to BMR for IET.