Patients with clinically isolated single cranial nerve palsies associated with diabetes or hypertension are likely to recover spontaneously within 5 months and initially require observation only. However, patients with unexplained binocular diplopia and those who progress or fail to recover should be investigated to establish the underlying aetiology and managed as appropriate.

The use of botulinum toxin A (BTXA) in childhood strabismus is still a matter of debate. This study investigates the indications for and outcome of BTXA therapy in children at our institution. From 1985 to 1995, 237 children up to and including 16 years of age were treated with BTXA for strabismus. We undertook a retrospective study of 163 (69%) children from this group. Factors considered were age; anaesthesia; number of, indication for and outcome of injections; complications and follow-up. There were three major indications for the use of BTXA in children: firstly to improve binocular function, secondly as a post-operative diplopia test or for cosmetic reasons, and thirdly in the investigation or treatment of paralytic and restrictive strabismus. In the first group (54 children), BTXA produced improved binocular function in 54% of all patients treated and in 49% of those with a minimum follow-up of 12 months. In the second group (82 children), 88% showed informative post-operative diplopia tests and 44% had more than one injection to maintain improved cosmetic alignment. The third group comprised 27 children with a range of diagnoses, including 1 third nerve paresis, 12 unilateral or bilateral sixth nerve pareses, 7 unilateral or bilateral Duane's syndromes, 5 lost or fibrosed muscles and 2 others. This group had a range of outcomes which are discussed in the text. BTXA is useful in the treatment of a select group of children with strabismus. If there is evidence of threatened or recently lost binocularity, or risk of creating or worsening diplopia after surgery, it is a useful therapeutic tool. In children with strabismus of unusual cause it has diagnostic value.

Thirty-four patients with surgically treated bilateral superior oblique palsy are presented. The patients are divided into three groups: Symmetrical palsies, Asymmetrical palsies, A group in whom the bilaterality was initially masked. Bilaterality should be suspected in all cases of traumatic IVth nerve paresis, and particularly in cases with a large 'V' pattern, excyclo deviation of more than 10 degrees on down-gaze and when right hypertropia switches to left hypertropia on lateral down-gaze. Bilateral Harada-Ito procedures alone 'cured' 11 of 17 patients (65 per cent) in groups 1 and 2, and is the operation of choice in acute bilateral superior oblique palsy. Cyclo deviation was reduced by a mean of 5.5 degrees in the primary position and by 6-10 degrees in down-gaze. Patients initially managed with other surgery had a more complicated surgical course and required more operations. Seven patients who initially demonstrated only gross fusion recovered good fusion after Harada-Ito surgery.

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SummaryDiplopia in the inferior field due to orbital trauma is a notoriously difficult and dis abling problem. Even if a blow-out fracture is repaired by current methods, patients may still have diplopia. There also exists another group in whom no demonstrable radiological fracture can be found, and yet there is a severe down gaze deficit.The possible mechanisms of this phenomenon are discussed and the results of hori zontal muscle transpositon surgery in a series of nine patients is reported.The authors conclude that this procedure is a valuable method of increasing the useful field of binocular single version in these patients.