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Temporary management of diplopia with botulinum toxin in multiple ocular motor cranial neuropathies

Purpose. To report management of diplopia with botulinum toxin injection in traumatic multiple ocular motor cranial neuropathies. Methods. Alternate prism and cover measurement of deviation in different positions of gaze, examination of ductions, field of binocular single vision, and complete ocular anterior and posterior segment evaluation were carried out. CT and MRI of the orbit were available. Results. We describe a case of traumatic VI, IV, and mainly superior III cranial nerve palsies, with left hypotropia of 35 prism diopters and esotropia of 45 prism diopters and incapacitating diplopia, due to fracture of the roof and lateral wall of the orbit, extending to the superior orbital fissure, as demonstrated by CT and MRI of the orbit. Severe limitation of abduction, elevation, and depression of the left eye was found. A single botulinum toxin injection in the medial rectus with diffusion to the inferior rectus was effective as a temporary measure for the treatment of diplopia and attainment of a small field of binocular single vision. The patient remained symptom-free for 5 months after injection. Conclusions. Botulinum toxin injection may be useful for the temporary management of diplopia in multiple ocular motor cranial neuropathies.