The use of voriconazole in the treatment of Aspergillus fumigatus keratitis

Botulinum toxin for the treatment of acute-onset concomitant esotropia in Chiari I malformation Acute-onset esotropia (ET) is a rare presentation of Chiari I malformation.The ET may resolve following neurosurgical decompression, although this is not usually immediate. 1Where neurosur- gery is not undertaken, Kowal et al 2 suggest prismatic correction or strabismus surgery.The latter may result in temporary correction of the strabismus, as the strabismus can recur and resolves only following decompression. 3Botulinum toxin (BT) has been reported as successful in one case where the ET did not resolve following neurosurgery. 4Despite BT being a common treatment for acute acquired concomitant ET, 5 no previous case has been reported in which BT was used prior to neurosurgical decompression for Chiari I malformation. Case reportA 16-year-old girl experienced diplopia during swimming, and presented to the A&E Department on the day of onset.She gave a history of occasional, brief diplopia.On examination, there was 16D ET at near and 20D ET at distance.The angle of deviation reduced on versions.Saccade to the right was possibly hypometric; no nystagmus was present.Over 2 weeks, the angle increased to 40D ET, saccades to the right became definitely hypometric and abducting nystagmus developed.MRI scan revealed Chiari I malformation with tonsillar descent to about 12 mm below the foramen magnum, with loss of cerebrospinal fluid (CSF) spaces indicating impaction of neural tissue (fig 1).Neurosurgery was discussed, but delayed for 8 months.Three months after onset, the angle had increased to 45D ET at near and distance.Four units of BTA were injected into the right medial rectus muscle with electromyographic guidance under topical anaesthesia.Initially there was an overcorrection (12DXT, 5DRHT, with -3K limitation right adduction).Following recovery of medial rectus function, 6D exophoria at near and 4D esophoria at distance were present.Eight months following BT injection there had been no recurrence of strabismus and the patient underwent neurosurgical decompression.Currently the patient is orthophoric and shows hypometric saccades to the right and left, and fine pendular-like nystagmus on right and left gaze.