Golden Indications and an Overview on the Use of Botulinum Toxin in Strabismus

Botulinum toxin A (BTXA) is considered a pharmacological agent that may provide an alternative treatment to surgery in strabismus. It can be used as both a diagnostic and therapeutic agent in various concomitant, paralytic, and restrictive disorders. The major advantage of BTXA treatment is that it is non-invasive and does not impact the patient's chance for future surgery in case of an unfavorable response. In some selected disorders, BTXA has become the primary choice of treatment, whereas surgery is found to be more effective in others. Accumulated knowledge and experience have demonstrated that BTXA is more than merely an alternative treatment and has additional specific indications such as in unstable deviations and as an adjunct to surgery. Patients with recurrent deviations despite multiple surgeries are also good candidates for BTXA treatment. Although the major expectation is to obtain a permanent result, BTXA can also be used as a maintenance treatment. This paper mainly focuses on the current indications for the use of BTXA in strabismology, with special emphasis on ideal first-choice applications referred to as "golden indications," within the scope of the author's own experience with the use of BTXA over 30 years.