# Botulinum Toxin Injection in Acute Sixth Nerve Palsy in a 1-Year-Old Child: Case Report, Management Strategy, and Review of Literature

## TL;DR

A 1-year-old child with acute sixth nerve palsy showed improved eye alignment and amblyopia recovery after botulinum toxin injection.

## Contribution

Demonstrates botulinum toxin as a safe and effective early intervention for pediatric sixth nerve palsy.

## Key findings

- Esotropia decreased from 50 to 20 prism diopters within one week of botulinum toxin injection.
- Ocular alignment normalized by eight weeks with mild residual ptosis and improved amblyopia.
- Botulinum toxin injection is a safe and effective treatment for acute pediatric sixth nerve palsy.

## Abstract

Sixth nerve palsy in children is a rare yet clinically significant condition that can result in strabismus and developmental complications. The acute onset of sixth nerve palsy can lead to esotropia, a sudden inward deviation of the eye due to impaired abduction. While most cases resolve spontaneously, botulinum toxin injection is gaining ground as a therapeutic intervention, particularly in pediatric patients with persistent or severe misalignment.

To evaluate the effectiveness of botulinum toxin injection in managing acute sixth nerve palsy in a 1-year-old child with esotropia. The therapeutic outcomes and a review of current evidence are discussed, focusing on the efficacy, safety, and timing of botulinum toxin therapy in pediatric sixth nerve palsy. Methods: We report the case of a 1-year-old child diagnosed with acute sixth nerve palsy and treated with botulinum toxin injection to the medial rectus muscle. Follow-up assessments were conducted at 1 week, 3 weeks, and 8 weeks to monitor ocular alignment and visual development. Results: At the one-week follow-up, esotropia decreased from 50 to 20 prism diopters, with moderate upper eyelid ptosis. At eight weeks, ocular alignment was normal, with mild residual ptosis and improvement in amblyopia.

Sixth nerve palsy in children is uncommon but can arise from various underlying causes. In most cases, it resolves within a few months, but in severe or persistent cases, therapeutic interventions such as botulinum toxin injections can alleviate symptoms. The clinical case highlights that early intervention with botulinum toxin is a safe and effective method for improving ocular alignment.

Botulinum toxin injection effectively improved ocular alignment and facilitated amblyopia recovery in this pediatric case of sixth nerve palsy, supporting its use as a safe adjunctive treatment in early intervention.