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Alteration of cyclic frequency by botulinum toxin injection in adult onset cyclic esotropia
  1. Y-H Lai1,
  2. D R Fredrick2
  1. 1Department of Ophthalmology, Kaohsiung Medical University Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
  2. 2Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
  1. Correspondence to: Yu-Hung Lai Department of Ophthalmology, Kaohsiung Medical University Hsiao-Kang Hospital, Kaohsiung Medical University, 100 Zihyou 1st Road, Kaohsiung, 807, Taiwan;

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Cyclic strabismus is an uncommon disorder in which strabismus comes and goes alternately, consistently, and repetitively over a period of time. In a 48 hour cycle, a 24 hour period of orthotropia would be followed by a 24 hour period of constant strabismus. Cycles of 24 hour1 to 96 hour2 patterns have been reported. Most cases have been described in children, and the aetiology of cyclic strabismus is still speculative.

Case report

A 57 year old woman was referred to Kaohsiung Medical University Hospital with the complaint of a periodic visual fluctuation of a “good day“ and a “bad day” alternately for about 6 months. She had diplopia on bad days. She did not have diabetes or hypertension. There was no history of strabismus, amblyopia, patching therapy, ocular trauma, or oculomotor palsy. She had received trials of Mestinon treatment by two neurologists. Except for pterygium excision 4 years earlier, other ocular and medical history were unremarkable. There was no family history of strabismus.

Her visual acuity was 20/25 with +1.25 lens RE and 20/20 LE plano. Cycloplegic refraction was +1.25 RE and +0.50 LE. The anterior segments were normal except for recurrent pterygia on the nasal limbus in both eyes. Ophthalmoscopic examination, ocular alignment (fig 1A), and ocular motility were normal. Since the initial examination was on her “good day,” she was asked to come back the next day—that is, on the “bad day.”

Figure 1

 (A) “Good day”—orthotropia; (B) “Bad day”—esotropia.

The next day, there was a 25 prism dioptre, commitant right esotropia (fig 1B) with full ocular motility. The visual acuity was unchanged. Brain and orbit magnetic resonance imaging studies were unremarkable except for a suspected small arachnoid cyst on the right side of the falx.

She received 2.5 U botulinum toxin (Botox) injection in her right medial rectus muscle (MR). The alignment was orthotropia 1 week after the injection. She was asymptomatic for about 2 months, but the cyclic pattern returned with a 96 hour cycle by patient history. A repeated 2.5 U Botox injection in right MR, which was given 3 months after the first, produced another asymptomatic period of 2 months. Two months after the second injection, she experienced constant strabismus without cyclic pattern, which persisted for about 1 year. She received right MR recession by 4 mm and right lateral rectus muscle resection by 5 mm for constant esotropia of 25 prism dioptres. After the surgery, the alignment was orthotropic and no recurrent of the cyclic pattern during 1 month of follow up. The stereopsis was 200 seconds of arc by Titmus test.


Adult onset cyclic strabismus is rare,2–8 and, to the best of our knowledge, only 10 patients have been reported. The reported cases of adult onset cyclic strabismus are summarised in table 1. The patients had various ages of onset between 21 and 67 years. Most reported cases demonstrated 48 hour cyclic patterns. The persistence of the cycles, if not interrupted by surgery, was as long as 7 years.8 It is interesting that adult onset cyclic strabismus occurs predominantly in females and is frequently related to ocular or orbital diseases, trauma, or surgery.4–8

Table 1

 Summary of the adult onset cyclic strabismus

Botox injection has been used as treatment of cyclic strabismus.7 However, no change of the cyclic pattern was mentioned. We noted that the cyclic pattern in our patient changed 3 months after the first Botox injection, and the cycles were eliminated 2 months after the second injection.

The characteristics of cyclic strabismus in children are an average age of onset between 3 and 4 years, moderate hyperopia, and moderate angle.3 However, a female preponderance was not noted in childhood onset cyclic esotropia. No pertinent explanation for cyclic strabismus has been reported. Although Botox only has a temporary effect, both Botox injection7 and eye muscle surgery3 produce good ocular alignment results. More evidence and further investigation are required to elucidate the mystery.


The authors thank Professor William F Hoyt and Professor Creig S Hoyt for their review and criticism of this letter.