Botulinum Toxin Injection Research Articles

Accommodation amplitude change after cosmetic use of the botulinum toxin in the upper face

Purpose Cosmetic botulinum toxin A (BoNT-A) injections are increasing worldwide. Adverse effects need to be evaluated in more detail for BoNT-A regulations. This study aims to assess the anticholinergic effect of BoNT-A on accommodation amplitude (AA) after upper face application. Methods Twenty patients aged between 20 and 45 years were recruited in this prospective, interventional study. Abobotulinum toxin A of 500 units was diluted with 3 ml saline and injected into the forehead, glabellar and periorbital area. AA was measured with both the push-up and minus-lens techniques before and after two weeks of the injections. T-test for normally distributed variables was applied for the comparison of the results. Results The study group comprised 18 women and 2 men with a mean age of 33.9 ± 8.59. AA decreased significantly after two weeks of the injection. In the push-up test, AA was 9.18 ± 4.72 D before BoNT-A injection and decreased to 7.11 ± 3.02 D after the injection (p < 0.001). In the minus lens test, AA reduced from 5.86 ± 2.24 D to 5.24 ± 2.06 D after BoNT-A injection (p < 0.001). Refraction did not change in any of the participants. Conclusion The present study showed that cosmetic upper face BoNT-A injections reduced AA. However, this reduction did not result in any significant symptomatic effects in the patients. These findings suggest that while BoNT-A injection has a measurable impact on the ciliary muscle or its parasympathetic innervation, it may not lead to noticeable clinical outcomes.

Intravesical Botulinum Toxin Injection for Treating Detrusor Overactivity and Poor Compliance in Posterior Urethral Valves-A Preliminary Experience.

To report our preliminary experience on the use of Botulinum toxin A in boys with posterior urethral valves for treating detrusor overactivity and/or reduced bladder compliance not responsive to medical treatment. Primary outcome measures studied were change in baseline end fill pressure (pDet), compliance, maximum Detrusor overactivity pressure (DO), fractional bladder capacity (FBC), vesicoureteric reflux (VUR) grade/resolution. Secondary outcome measures were serum creatinine and estimated glomerular filtration rate (eGFR). Low compliance group was defined as rise in baseline pDet > 20 cmH2O. High pressure DO was defined as maximum pDet > 40 cmH20. A total of 15 children were included in the analysis. The median decrease in end fill pDet in the whole cohort was from 20 cmH2O (14.5-30) to 16 cmH2O (10.5-22) (p = 0.065). By analyzing the patients with low compliance, we identified a median decrease in end fill pDet from 32 cmH2O (26.5-44.5) to 19 cmH2O (16.5-25.5) (p = 0.028). The median change in compliance for all the boys was from 6 mL/cmH2O (4.51-7.3) to 12.1 mL/cmH2O (7.44-17.3) (p < 0.001). The median change in compliance in the low compliance group was from 5.5 mL/cmH2O (4.42-7.1) to 8.8 mL/cmH2O (7.39-13.3) (p = 0.018). The median change in fractional bladder capacity for all the boys was from 0.70 (0.55-0.92) to 0.98 (0.79-1.42) (p = 0.061). A complete resolution of DO was observed in 7 out of 11 patients. Complete resolution of VUR was observed in 5 out of 8 renal units. Botulinum toxin A can be considered in the treatment strategy for reduced bladder compliance and detrusor overactivity in boys with PUV. 15894.

Trends in spasticity-reducing surgery and botulinum toxin treatment for post-stroke spasticity: a register study on 6,258 patients in Sweden, 2010-2021.

To assess trends in upper and lower extremity spasticity-reducing surgery and botulinum toxin A (BoNT-A) treatment. A national cohort register study. Upper and lower extremity spasticity-reducing surgery and BoNT-A treatment in Swedish stroke patients over a 12-year period was assessed using the National Patient Register. A total of 6,258 patients were treated during this period; their mean age was 58, and the majority were male. In both upper and lower extremities, tenotomy was the most common surgical procedure, followed by tendon lengthening. The need for BoNT-A injections was significantly reduced after surgery compared with before surgery. The total number of BoNT-A treatments increased during the study period, and ultrasound guidance of injections became more common. The frequency of BoNT-A treatments was significantly reduced in patients who underwent surgery. Even though no causative association can be established due to the nature of these registry data, this may indicate that surgery reduces the need for further BoNT-A treatments.

A National Survey on Retrograde Cricopharyngeus Dysfunction Practice Patterns Among Laryngologists.

Retrograde cricopharyngeus dysfunction (RCPD) is characterized by the inability to belch, abdominal bloating, and distension, as well as socially awkward gurgling noises and excessive flatulence. The use of various diagnostic tools remains variable, while the national incidence of preference among laryngologists toward management remains unknown. This study aims to analyze trends and practice patterns in the diagnostic workup and management of RCPD among academic laryngologists. By doing so, our goal is to elucidate clinical decision-making patterns and treatment outcomes associated with the management strategies for RCPD. An electronic survey was sent to 184 academic laryngologists. The survey assessed RCPD topics related to patient demographics, clinical characteristics, knowledge and experience levels, perceived importance of historical and physical factors in diagnosis, diagnostic workup and utility, the effectiveness of different management approaches, and specifics of botulinum toxin (BT) injection practices. Of the 87 (47.2%) laryngologists who responded to the survey, 75.9% have heard of RCPD before. The most common management approaches were BT injections (79.2%) and cricopharyngeus myotomy (11.3%). The mean amount of BT injected by laryngologists was 59 units. The survey demonstrates that RCPD is likely conceived as a clinical diagnosis among practicing laryngologists. While BT injections are done more frequently and are perceived to be effective, the role of myotomy of the cricopharyngeus remains variable.

Efficacy of intragastric botulinum toxin A injection on patients with side effects caused by intragastric balloon placement intolerance: A case series study.

Obesity is a global health concern, with intragastric balloon (IGB) placement serving as a nonsurgical intervention for weight management. However, intolerance due to severe gastrointestinal side effects often leads to premature removal, limiting its effectiveness. Botulinum toxin A (BTX-A) injection has been proposed as a potential strategy to improve IGB tolerance by modulating gastric motility. This study reports a case series of patients who developed severe intolerance to IGB placement, including persistent nausea, vomiting, fluid intolerance, dehydration, and reduced urine output, necessitating medical intervention. Patients were diagnosed with IGB intolerance due to obstructive gastric effects, characterized by impaired gastric emptying and intolerance to oral fluids, leading to dehydration and electrolyte imbalances. A total of 14 patients with IGB intolerance were treated with 500 U of BTX-A injected around the pyloric canal. Prokinetic drugs were also administered to support gastric motility. Patients were monitored for 6 months following the intervention. Among the 14 patients, 11 (78.57%) showed a significant improvement in fluid tolerance within 12 hours of BTX-A injection and were able to retain the IGB without additional complications. Three patients (21.43%) did not improve and required early IGB removal. No major adverse effects related to BTX-A injection were observed. BTX-A injection appears to be a promising adjunctive therapy to improve IGB tolerance in patients experiencing severe intolerance. These findings suggest a potential role for BTX-A in reducing the need for premature balloon removal, thereby enhancing weight loss outcomes. However, further randomized controlled trials with larger sample sizes are needed to confirm its efficacy, optimize dosage, and establish standardized treatment protocols.

Anatomical consideration for botulinum toxin injection of the frontalis muscle based on analysis of intramuscular innervation

The facial nerve is the seventh cranial nerve, and its temporal branch (TBFN) innervates the frontalis muscle. Peripheral nerve disorders involving the facial nerve can lead to facial palsy, for which a common non-invasive treatment approach is to inject a chemodenervation agent such as botulinum toxin (BoNT). The purpose of this study was to provide anatomical suggestions for BoNT injection sites in the frontalis muscle based on the intramuscular innervation pattern of the TBFN as identified objectively using Sihler’s staining. Nineteen hemifaces containing the TBFN and the frontalis muscle were harvested from 15 embalmed cadavers according to facial landmarks. The frontalis muscle was divided into 16 areas to identify the prevalence rates of distal nerve endings and the arborization pattern of the TBFN after applying Sihler’s staining. Distal nerve endings of the TBFN were most commonly found in area B2 (17 of 19 specimens, 89.5%), followed by in area B3 (n = 15, 78.9%). No distal nerve ending was observed in area A1. Two types of the arborization pattern of the TBFN were observed. We propose four BoNT injection sites based on the intramuscular innervation pattern of the TBFN in the frontalis muscle as identified using Sihler’s staining.

Ultrasound Imaging and Guidance for Bell's Palsy: EURO-MUSCULUS/USPRM Approach.

Bell's palsy, or idiopathic peripheral facial nerve palsy, is characterized by the sudden onset of facial muscle paralysis resulting from damage to the facial nerve fibers. The diagnosis is typically established through clinical evaluation, although in cases with atypical features, imaging modalities like magnetic resonance imaging (MRI) or computed tomography (CT) are indicated to rule out underlying lesions or temporal bone abnormalities compressing the facial nerve. High-resolution ultrasound (US) has emerged as a promising modality for evaluating peripheral neuropathies, including cranial nerve disorders. Recent studies have highlighted its potential in measuring facial nerve diameter, detecting nerve edema, and predicting clinical prognosis in Bell's palsy. Beyond its diagnostic role, US also facilitates precise perineural corticosteroid injections, offering an alternative to systemic corticosteroid therapy, which is commonly associated with adverse effects such as hyperglycemia and hypertension. US also plays a crucial role in guiding botulinum toxin (BoNT) injections, which are used to manage synkinesis and facial asymmetry in chronic Bell's palsy cases.This review discusses the role of US in the diagnosis and management of Bell's palsy, emphasizing its advantages in visualizing facial nerve edema and guiding perineural corticosteroid and intramuscular BoNT injections.

Psychometric benefits of adding bolt-ons to the EQ-5D-5L in populations undergoing minimally invasive cosmetic procedures.

There is growing interest in measuring health outcomes associated with minimally invasive cosmetic procedures (MICPs), such as botulinum toxin and hyaluronic acid injections. However, the EQ-5D may have limited content validity for this purpose. This study aims to psychometrically test five additional dimensions ('bolt-ons') for the EQ-5D-5L in individuals planning or undergoing MICPs. In 2023, a cross-sectional, online survey was conducted with 149 women planning MICPs and 215 who had recently undergone them. Respondents completed the EQ-5D-5L, five bolt-ons (skin irritation, self-confidence, sleep, social relationships, tiredness), the Rosenberg Self-Esteem Scale (RSES) and the Brief Fear of Negative Evaluation Scale-Straightforward Items (BFNE-S). The following psychometric properties were tested for the EQ-5D-5L + bolt-on(s): ceiling, convergent and divergent validity, explanatory power and known-groups validity. Adding tiredness (22%), self-confidence (23%) or sleep bolt-ons (27%) substantially reduced the ceiling of the EQ-5D-5L (47%). The self-confidence and social relationships bolt-ons showed a moderate or strong correlation with the RSES and BFNE-S total scores (-0.462 to -0.679). The tiredness and self-confidence bolt-ons improved the EQ-5D-5L's explained variance in EQ VAS scores from 37% to 45%. The self-confidence and social relationships bolt-ons improved the EQ-5D-5L's discrimination between known groups based on self-esteem and bodily appearance (relative efficiency: 2.72 to 2.82). Relevant bolt-ons substantially enhance the psychometric performance of the EQ-5D-5L in MICP populations. The self-confidence and tiredness bolt-ons may be recommended as primary choices for use alongside the EQ-5D-5L, both in clinical studies and as part of sensitivity analyses in economic evaluations of MICPs.

Real-life prognosis of neurological complications of botulinum toxin: A nationwide pharmacovigilance study of adverse drug reactions reported in France between 1994 and 2020.

Real-life prognosis of neurological complications of botulinum toxin: A nationwide pharmacovigilance study of adverse drug reactions reported in France between 1994 and 2020.

From risk factors to treatment: a holistic approach to managing bruxism

Introduction and purpose Bruxism, characterized by involuntary clenching or grinding of teeth, affects individuals across all age groups, often leading to significant oral health complications and diminished quality of life. While its etiology is multifactorial, involving genetic, psychological, and physiological factors, the management of bruxism remains challenging due to the variability in its presentation. This study aims to characterize bruxism and evaluate various therapeutic interventions, including pharmacological treatments, botulinum toxin injections, occlusal splints, and non-invasive methods such as cognitive behavioral therapy (CBT), biofeedback therapy (BFT), and physiotherapy. Materials and methods A comprehensive review of recent clinical trials and studies was conducted, focusing on the efficacy, safety, and limitations of both invasive and non-invasive interventions. State of knowledge Botulinum toxin injections and dry needling demonstrated significant efficacy, though their effects were temporary. Non-invasive therapies, including CBT and BFT, were noted for their safety but showed limited effectiveness. Combining sleep hygiene with mindfulness practices produced promising results, particularly in children. Physiotherapeutic methods, such as manual therapy and home exercises, helped alleviate muscle tension and pain. Conclusions While bruxism management has advanced with diverse treatment options, challenges persist, particularly concerning the durability of effects and patient compliance. A multidisciplinary approach integrating psychological, physical, and pharmacological strategies appears essential for optimal outcomes. Further research is needed to refine therapies and establish long-term efficacy.

Determination of optimal points for botulinum toxin injections in the treatment of patients with temporomandibular myofascial pain syndrome

To understand the processes occurring during the development of temporomandibular myofascial pain syndrome, a clear description of the anatomical components is necessary. In the literature, the term «stomatognathic system» is used for this, the elements of which are the temporomandibular joint, masticatory muscles and the dental periodontal complex. Each component of the system is influenced by a number of factors, primarily psychological, which causes the subjectivization of clinical manifestations from headaches to pathological tooth cutting and the development of temporomandibular joint dysfunction. One of the methods of treating this pathology is to inject botulinum toxin type A into the chewing muscles. However, the question of the choice of methods of administration of botulinum toxin and its dosage remains relevant.Materials and methods. Botulinum toxin injections were performed outside and intraoral in 30 patients with temporomandibular myofascial pain syndrome. The effectiveness of the therapy was evaluated on the basis of clinical examination data, analysis of the degree of mouth opening before the start of treatment, after 14 days, 6 and 12 months.Results. The high efficiency of botulinum toxin type A injections in the treatment of the above pathology has been proven.Conclusion. It is important to evaluate the effectiveness of treatment based on the developed clinical examination methods, if necessary, correct it in a timely manner at all stages of treatment and follow-up of patients with temporomandibular myofascial pain syndrome.

Botox injections with and without general anesthesia for pediatric sialorrhea: A cost, efficacy, and safety analysis.

Botox injections with and without general anesthesia for pediatric sialorrhea: A cost, efficacy, and safety analysis.

The role of Botulinum Toxin for the Management of post Parotidectomy Sialocele: A Randomized Controlled Trial.

Parotid fistula or Sialocele is a general consequence of a penetrating injury of parotid gland or parotidectomy surgery which may be caused serious complications. Studies show different approaches had various effects on management of sialocele complications after parotidectomy. The purpose of this study is to evaluate the effects of botulinum toxin (BTX) on total/ partial and partial superficial parotidectomy complications. Patients with benign parotid gland tumors were included in this bicentric, double-blind, parallel, randomized clinical trial from 2021 to 2023. One hundred subjects underwent parotidectomy with/ without BTX injection were randomly assigned into two groups including the intervention (BTX group) (n = 50) and control group (n = 50) then the clinical information of all mentioned patients was assessed. Hematoma, infection, opening of the wound, warmth or swelling was not observed in either group. BTX group had significantly lower Postoperative drainage volume versus control group on both 24 and 48h after surgery (23 vs. 19 mL, P < 0.02 at first day and 27 vs. 12, p = 0.003 at second day). Although the incidence of sialocele was lower in the BTX group than the control group (2/50 [4%] vs. 6/50 [12%]) with (p = 0.269) but it wasn't significant. The study results demonstrated that botulinum toxin may be safe and effective therefore BTX injection in improving parotidectomy complications like sialocele was recommended.

Submental Microneedles of Botulinum Toxin A for Double Chin After Neck Injection.

Neck injections of botulinum toxin A (BTX-A) are an effective, minimally invasive approach to improve lower face sagging, especially in Asian populations. However, cases of worsened "double chin" have been observed postinjection, likely due to the platysma muscle type and limited anterior neck injection range, which may result in compensatory platysma contraction. Five female patients who developed aggravated double chin after BTX-A injections in the lower jaw and neck were treated with microneedle BTX-A injections (10-20 U in 3-4 rows with 0.5-1 cm between points). Effective submental lifting and double chin improvement were observed within 5-10 days, with no reports of voice changes or dysphagia. This microneedle BTX-A injection technique provides a safe, effective solution for enhancing the anterior neck region and can serve as an important adjunct to lower face antiaging treatments.

Microneedle for Botulinum Toxin: A Randomized, Case-control, Single-blind Study to Assess Clinical Efficacy and Patient Satisfaction.

Lateral canthal lines can be effectively treated with injections of botulinum toxin, whereas the aesthetic effects can vary due to factors such as injection depth, which is essential for achieving predictable clinical outcomes. Microneedles (MNs) have proven effective in intradermal skin rejuvenation procedures. However, a comparison of their performance with traditional needles is still lacking in the scientific literature to reliably evaluate their efficacy.This study is therefore aimed to evaluate the clinical efficacy and patient satisfaction of botulinum toxin A injected intradermally using a standard needle versus an MN device. Twenty recruited participants received a single injection of 10 Speywood Units (US, 0.05 mL) for each of the six standard points (total dose: 60 US) at T0 using both the control needle and the MN, randomly assigned.Follow-up visits were scheduled at 30 (T1) and 90 (T2) days, along with patients and blind observer evaluation of the clinical improvement of periocular wrinkles. The measurement of wrinkle depth showed that MN injection had similar efficacy to a normal needle, whereas blind evaluation indicated better results for the MN. Patient subjective assessments of procedure pain/discomfort and likelihood of repeating the procedure also favored the MN. This pilot study suggests that the MN device holds promise for optimizing the clinical results of botulinum toxin injections by controlling injection depth and enhancing patient acceptance and injection experience compared to standard needle injection. The absence of adverse events further supports the efficacy of MN for intradermal botulinum toxin use.

A Comparative Study of Platysmal Myoneurectomy With Variations of Selective Neurectomies in Post-Facial Palsy Synkinesis.

Synkinesis is a distressing sequela of facial palsy. The main treatment for this condition has been Botulinum toxin injections. However, more recently, selective neurolysis/neurectomies have shown promise, with some variations in practice evolving over time. A clinical review of practice was performed on sixty-eight patients (n = 68) with Bell's palsy over five years (2018-2023) who underwent synkinesis surgery, following facial palsy. Comparisons were made between platysmal myoneurectomy only (Group I), platysmal myoneurectomy and zygomaticus major/levator labii superior direct neurotization (Group II), platysmal myoneurectomy and depressor anguli oris (DAO) selective neurectomy (Group III) and platysmal myoneurectomy + DAO and buccinator selective neurectomies (Group IV). The following outcome measures were used: Sunnybrook Facial Grading Scale (FGS), Facial Clinimetric Evaluation (FaCE), Facial Disability Index (FDI), and Synkinesis Assessment Questionnaire (SAQ). Statistical analyses were performed using the student's t-test and ANOVA. There was an overall improvement for patients pre- and post-operatively (42.34 ± 16.37 vs. 65.12 ± 14.34; Student's t-test, p < 0.0001). All FGS scores showed statistically significant (p < 0.05) improvement. FDI-physical, SAQ, and FaCE showed statistically significant improvements, apart from the FDI-social (p = 0.08). Qualitatively, all procedures showed significant improvement compared with their pre-op state, with Group IV showing the best results among platysmal myoneurectomy variants in terms of repose, volitional movements, and synkinesis reduction compared with its contemporaries.

Pain Reduction with Repeated Injections of Botulinum Toxin A in Upper Limb Spasticity: A Longitudinal Analysis from the ULIS-III Study

Pain reduction is a common goal of the treatment of upper limb spasticity with botulinum toxin (BoNT-A). ULIS-III was a large international, observational, longitudinal study (N = 953) conducted in real-life clinical practice over two years. In this secondary post hoc analysis, we examine whether goals for pain reduction were met over repeated injection cycles. We report serial changes in pain severity and explore predictors of pain reduction and injection frequency. Patients were selected if pain reduction was a primary/secondary goal for at least one cycle (n = 438/953). They were assessed at the start and end of each cycle using the goal attainment T-score alongside a self-report of pain severity (range 0–10). Across all cycles, pain-related goals were set for 1189/1838 injections (64.7%) and were achieved in 839 (70.6%). Patients continued to show a significant reduction in pain (p &lt; 0.001) for each injection up to seven cycles, with some cumulative benefit (p &lt; 0.001). Those requiring more frequent injections tended to have higher starting pain scores and a smaller reduction in pain score, but these differences were not significant when other covariates (age, previous injection history, time since onset, severity and distribution of spasticity) were taken into account (p &gt; 0.713). Conclusion: Repeated BoNT-A administration continued to result in a significant reduction in upper limb spasticity-related pain, regardless of patient-related factors.

Deep, posterior muscles of the neck. A proposal for injection procedures.

Deep, posterior muscles of the neck. A proposal for injection procedures.

Clinical response to placebo botulinum toxin injection in cervical dystonia—a systematic review and meta-analysis

BackgroundCervical dystonia is the most common form of focal dystonia and is the most studied neurological condition in patients receiving botulinum toxin. In clinical trials of botulinum toxin, there is a placebo response, but this has not been studied systematically.ObjectivesA systematic review and meta-analysis were conducted to assess and compare the peak and duration of placebo response in people with cervical dystonia receiving botulinum toxin in randomized, blinded controlled clinical trials.MethodsThree databases (Embase, PubMed, Scopus) and two trial registers (Cochrane CENTRAL and Cochrane Movement Disorders Trials Register) were searched by a biomedical librarian in May 2022 and September 2023. Covidence was used for screening titles and abstracts and full text. Two authors independently screened each record and collected data from the included articles. Microsoft Excel was used for data collection. The Cochrane Collaboration’s Risk of Bias tool in randomized trials was used by two authors for each included study. A third author resolved conflicts during screening and discrepancies during data collection and risk of bias assessment. We conducted a random-effects meta-analysis of the mean reduction in the TWSTRS total score at 4 weeks post injection, to assess the clinical change in the placebo arm overall and by TWSTRS pain, severity, and disability scales.ResultsTwelve studies, with moderate overall risk of bias, that included 2,145 participants with 580 randomized to placebo, were included in the systematic review. Clinical changes in the placebo arm were mild with a mean reduction of Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total score of 3.5 [95% confidence interval (CI): 2.6–4.4] 4 weeks post injection. TWSTRS pain score at week four was 0.9 (95% CI: 0.6 - 1.1; I2 = 59%). TWSTRS severity score at week four was 1.7 (95% CI: 1.3–2.0; I2 = 63%). TWSTRS disability score at week four was 0.7 (95% CI: 0.3–1.0; I2 = 63%). Duration of benefit ranged from 45.1 to 76.3 days with a mean duration of 57.6 days. Dropouts in patients randomized to placebo were due to lack of efficacy, pain, neck weakness, fatigue, and tiredness.ConclusionThis information on placebo response will be useful in estimating sample size and interpreting participant benefit in future interventional studies of cervical dystonia.

Screening of Clinical Data of Patients with Abnormal Head Posture and Investigation of Abnormal Head Posture Change After Treatment.

To analyze the clinical characteristics of patients with abnormal head posture (AHP) due to ocular causes and investigate the effect of treatment on the change in AHP. Patients with AHP admitted to the strabismus unit of our clinic between 2011 and 2022 were retrospectively analyzed. The patients' clinical and demographic data and change in AHP after treatment were recorded. A total of 172 patients, 86 females (50%) and 86 males (50%), with a mean age of 14.1±13.9 years were included in the study. The most common ocular causes of AHP were fourth cranial nerve palsy (50%), Duane retraction syndrome (16.9%), and A-V pattern strabismus (15.1%). Sixth cranial nerve palsy, third cranial nerve palsy, nystagmus blockade syndrome, extraocular muscle fibrosis, Brown syndrome, oculocutaneous albinism, and heavy eye syndrome were diagnosed less frequently. The most common AHP type was head tilted position (52.3%), followed by head turned (40.1%), chin down/up (3.5%), and combined form (4.1%). There was a significant relationship between AHP type and diagnosis (p<0.001). Amblyopia was present in 55 (35.7%) and absent in 99 (64.3%) patients. There was a significant relationship between amblyopia and both diagnosis (p<0.001) and AHP type (p=0.003). Of 172 patients, 100 (58.1%) underwent strabismus surgery, 10 (5.8%) had botulinum toxin injection, and 2 (1.2%) were prescribed prism glasses. Sixty patients (34.9%) were only followed up. Among 94 patients who continued follow-up, AHP was reduced in 77.3% and completely resolved in 16.7% of patients treated surgically, and was reduced in 50% and completely resolved in 25% of those treated with botulinum toxin. The causes of AHP are varied. Ophthalmological and orthoptic examinations should be performed in patients presenting with AHP, and strabismus surgery or botulinum toxin administration may reduce or completely correct AHP in eligible patients.