BOTOX injection to treat strabismus after infant botulism type B infection

The significance of botulinum toxin to ophthalmologists is twofold. Botulism, a medical emergency, frequently presents with ocular findings including blurred vision, diplopia, ptosis, and photophobia as a result of the neurotoxin produced by Clostridium botulinum. However, botulinum toxins also have therapeutic uses for medical conditions including strabismus. The safety and efficacy of Botulinum toxin A in patients with a history of botulism has not been reported.

We report a 9-week-old infant, diagnosed with type B toxin positive infant botulism treated with human botulism immune globulin, who developed a large angle exotropia. The infant was treated with intramuscular injections of botulinum toxin A to the extraocular muscles resulting in a favorable initial response but ultimately required strabismus surgery. Clinical manifestations and management of botulism are reviewed and botulinum toxin in the treatment of pediatric strabismus is discussed.

This case demonstrates safe administration of onabotulinumtoxinA to an infant with a history of antitoxin-treated botulism, resulting in a transient improvement in control of infantile exotropia.