Botulinum Toxin A Augmentation of Strabismus Surgery for Large-Angle Strabismus: A Retrospective Case Series and Literature Review

Purpose To report the results of botulinum toxin A (BTA)–augmented bilateral recession or monocular recession/resection surgery in a case series of patients with large-angle strabismus and review the relevant literature. Methods This retrospective study reviewed the medical records of 24 patients treated with BTA-augmented strabismus surgery for large-angle horizontal strabismus (55 prism diopters or greater) with a minimum 6-month follow-up. Patients underwent unilateral recession-resection or bilateral rectus muscle recession surgery with intraoperative BTA injection into the recessed muscle(s). Main outcome measures were postoperative angle of deviation and success rate, defined as a final deviation of 10 prism diopters or less. Results Of 24 patients (20 esotropia, 4 exotropia), the mean age was 9.2 years (range: 1 to 64 years). Mean preoperative deviation was 61.2 prism diopters for esotropia and 66.2 prism diopters for exotropia. Mean final postoperative deviation was 6.6 prism diopters for esotropia and 14.5 prism diopters for exotropia. Successful outcomes were achieved in 75% of patients with esotropia and 50% of patients with exotropia. Conclusions BTA augmentation of conventional strabismus surgery dosages is a promising approach for managing large-angle strabismus, particularly esotropia. Optimal patient selection and follow-up are needed to maximize surgical success rates. [ J Pediatr Ophthalmol Strabismus . 2025;62(1):5–11.]