Botulinum toxin application in children with strabismus and cerebral palsy at a rehabilitation center
Aplicación de toxina botulínica en niños con estrabismo y parálisis cerebral en un centro de rehabilitación
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Síndrome de bloqueo capsular intra-operatorio. A. Durante el proceso de hidrodisección se aprecia el avance de la solución por debajo de la corteza posterior (1), se observa el margen de la capsulorrexis (2). B. Presurización momentánea de la cámara anterior, se aprecia el contacto íntimo entre el núcleo y la capsulorrexis (3). C. Formación de una línea transversa en la cápsula posterior (4), se advierte el borde de la capsulorrexis (5). D. Ruptura de cápsula posterior (6), se delimita el defecto capsular mediante flechas." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Miguel Ángel Ibañez-Hernández, José Navarro-Partida, Alejandro González-de la Rosa" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Miguel Ángel" "apellidos" => "Ibañez-Hernández" ] 1 => array:2 [ "nombre" => "José" "apellidos" => "Navarro-Partida" ] 2 => array:2 [ "nombre" => "Alejandro" "apellidos" => "González-de la Rosa" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0187451911907599?idApp=UINPBA00004N" "url" => "/01874519/0000008500000004/v0_201306251234/X0187451911907599/v0_201306251235/es/main.assets" ] "itemAnterior" => array:16 [ "pii" => "X0187451911907572" "issn" => "01874519" "estado" => "S300" "fechaPublicacion" => "2011-10-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Mex Oftalmol. 2011;85:185-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4505 "formatos" => array:3 [ "EPUB" => 37 "HTML" => 3736 "PDF" => 732 ] ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Facoemulsificación de núcleo luxado a vítreo (técnica de Lima)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "185" "paginaFinal" => "188" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Phacoemulsification of luxated nucleus to vitreous (Lima technique)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090757fig1.jpg" "Alto" => 595 "Ancho" => 937 "Tamanyo" => 61109 ] ] "descripcion" => array:1 [ "es" => "¿ Figura 1. Vitrectomía tres puertos." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Julio Cesar Lima-Carro" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Julio Cesar" "apellidos" => "Lima-Carro" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0187451911907572?idApp=UINPBA00004N" "url" => "/01874519/0000008500000004/v0_201306251234/X0187451911907572/v0_201306251234/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Botulinum toxin application in children with strabismus and cerebral palsy at a rehabilitation center" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "189" "paginaFinal" => "195" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ivonne Segura-Rangel, Amelia Castellanos-Valencia" "autores" => array:2 [ 0 => array:3 [ "nombre" => "Ivonne" "apellidos" => "Segura-Rangel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Amelia" "apellidos" => "Castellanos-Valencia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Pediatric Ophthalmologist and Strabismologist, TELETON." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Pediatrician, Master of Science (MS). Child Rehabilitation Center, Occidente, México." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicación de toxina botulínica en niños con estrabismo y parálisis cerebral en un centro de rehabilitación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig1.jpg" "Alto" => 479 "Ancho" => 1945 "Tamanyo" => 138349 ] ] "descripcion" => array:1 [ "en" => "¿ Table 1. Mean comparison of strabismus angle following a single application of botulinum toxin." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">¿ Introduction </span></p><p class="elsevierStylePara">Pediatric cerebral palsy (PCP) is a permanent non-progressive disorder of movement and posture caused by cerebral injury at the development stage.<span class="elsevierStyleSup">1</span> It has the first place on the list of disability problems during childhood. Two thirds are associated with mental disability and 50% to 60% to visual disorders and strabismus.<span class="elsevierStyleSup">2</span> The first articles about the treatment (and follow up) of strabismus with botulinum toxin (BT) in children were done by Scott starting in 1980, where he mention treating endotropy and exotropy even with previous surgery.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The strabismus treatment in children with PCP is difficult due to their overall health condition. Frequently, these children have motor skills disorders and severe systemic complications that lead to sensory and motor deterioration.<span class="elsevierStyleSup">4,5</span> Neurologic instability and the disorders of the cortical and subcortical control centers are destabilizing factors of the surgical outcomes that result in hypercorrections in the medium and long term. These results can be attributed to the poor fusion potential.<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Several studies have described the harmlessness and therapeutic usefulness of the botulinum toxin for several types of strabismus, such as congenital endotropy, intermittent constant exotropy and paralytic strabismus.<span class="elsevierStyleSup">7</span> Other less studied field is strabismus in patients with systemic diseases and psychomotor delay; where variable angle and vertical strabismus are described as more frequent<span class="elsevierStyleSup">4,8</span> and with PCP are described as less frequent.<span class="elsevierStyleSup">8,9</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ Objective</span></p><p class="elsevierStylePara">To assess the results obtained after the treatment of strabismus in patients with neurologic deterioration, with systemic motor disorders and with different degrees of mental disability that delay or make impossible the surgical treatment. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ Methods</span></p><p class="elsevierStylePara">Prospective clinical study with self controls done between July 2008 and January 2010. All patients signed informed consent forms and the study was approved by the research council. Children of all ages that came to an ophthalmology appointment were included. Each one of them was fully evaluated by a rehabilitation specialist and they also had a previous diagnostic of PCP associated with horizontal strabismus, with or without mental disability and with any type or extension of the cerebral injury and the disability degree.</p><p class="elsevierStylePara">All patients underwent a full ophthalmologic examination to assess: visual acuity (using optotypes for verbal children who cooperate), visual conduct profile, fixation of luminous stimuli and of different objects (for children who do not cooperate).<span class="elsevierStyleSup">10</span> Patients were grouped according to the WHO (World Health Organization) visual acuity classification: normal or better (20/60); subnormal (20/70 - 20/200); severe deterioration (< 20/200 of size perception); and blindness (no perception of light).<span class="elsevierStyleSup">11,12</span> This last class was an exclusion criterion. The type of strabismus, endotropy or exotropy was assessed by alternate cover and cover-uncover tests; and its severity was measured in prismatic dioptres with the Krimsky method, evaluating fixation preference and muscular balance. In cooperative children we also performed the following tests: biomicroscopy, ophthalmoscopy, slit-lamp examination under cycloplegia with 1% cyclopentolate and full refraction tests.<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara">Based on their IQ score, the patients were classified by the International Classification of Diseases 10th Revision (ICD-10) in the following way: Mild mental retardation (MR), IQ range 50 to 69 (in adults, mental age from 9 to under 12 years); Moderate MR, IQ range of 35 to 49 (in adults, mental age from 6 to under 9 years); Severe MR, IQ range of 20 to 34 (in adults, mental age from 3 to under 6 years); Profound MR<span class="elsevierStyleBold">, </span>IQ under 20 (in adults, mental age below 3 years).<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">PCP was classified according to posture, motor control and functional activity limitation.<span class="elsevierStyleSup">1,14</span></p><p class="elsevierStylePara">All the children underwent strabismus treatment with BT type A diluted at 5 IU/0.1 mL.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Application technique:</span> the BT was infiltrated under sevoflurane sedation, with previous instillation of topic tetracaine in the eye being treated, after transconjutival muscle identification, direct application with 27 G needle and without electromyographic guide at the following dose: 5 IU in the horizontal rectus muscle for strabismus below 20 dp, in the medial rectus for endotropy and in the lateral rectus for exotropy. In strabismus of 20 - 40 dp 5 IU were used in the two horizontal rectus muscles: medial rectus for endotropy and lateral rectus for exotropy. For strabismus above 40 dp we used 7.5 IU and 5 IU in horizontal rectus muscles for the non-fixating and the fixating eye respectively. The patients were summoned back for an assessment appointment at 2, 4, 6 and 12 months after treatment to measure the angle deviation and to undergo a second and third dose after the sixth month according to the size of an angle above 15 dp. The frequencies of the patients' characteristics were described with averages, standard deviation and proportions. The averages of numeric dependent variables were compared before and after treatment with Student's t-test for related samples. We evaluated the response to treatment according to age, type of strabismus, visual acuity, degree of MR and degree of PCP disability with ANOVA. SPSS Ver.19 was used for statistical analysis. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ Results</span></p><p class="elsevierStylePara">Forty five patients were included in this study: 21 (46.7%) were male and 24 (53.3%) were female, the age range being between 1 and 18 years old and the mean age of 7 years old. The minimum follow up period was 1 year.</p><p class="elsevierStylePara">The PCP motor assessment revealed: anatomic presence of quadriparesia in 35 patients (77.8%) and the most frequent; followed by diparesis in 8 (17.8%), hemiparesis in 1 (2.2%) and paraparesis in 1 (2.2%). According to the type of injury, the spastic type had the highest incidence in 34 patients (75.6%), followed by the hypotonic type in 4 (8.9%), the dyskinetic type in 3 (6.7%), ataxic and mixed types in 2 patients respectively. According to the degree of disability to perform everyday activities we found 28 severe cases (62.2%); 13 (28.9%) were moderate cases and 3 (6.7%) were mild cases. Based on the intellectual function, 34 (75.6%) patients were classified with severe and profound MR, 2 (4.4%) had mild MR and 4 (8.9%) were normal.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Assessment based on type of strabismus:</span> 21 patients had endotropia with a deviation angle between 18 and 60 dp. Two months after treatment 17 (89.5%) of them had good results with hyper-corrections from 2 to 66 dp and a residual angle below 15 dp. After 4 months, 8 (42.1%) of them achieved. After 1 year, 5 (35.7%) of them was successful (<span class="elsevierStyleBold">Table 1</span>).</p><p class="elsevierStylePara"><img src="321v85n04-90090758fig1.jpg" alt="¿ Table 1. Mean comparison of strabismus angle following a single application of botulinum toxin. "></img></p><p class="elsevierStylePara">A total of 24 patients had exotropy with a mean deviation angle between 20 and 60 dp. After 2 months, 8 (45%) were successful cases with hypercorrections of up to 10 dp. After 4 months, 3 (18%) cases were still successful. And after 1 year, only 1 case (<span class="elsevierStyleBold">Table 1</span>).</p><p class="elsevierStylePara">Of 17 treated cases with endotropy and exotropy and a mean correction angle of 35.8 dp, in endotropy and 34.2 dp in exotropy, the success rate for endotropy after 2 months was 5 (62.5%) cases with a mean angle of 8.6 dp and 2 (28%) successful exotropy cases. After 4 months, in the endotropy group we had 2 (33.3%) successful cases with a mean hypercorrection of 16.6 dp and in the exotropy group we have none. After 1 year of treatment, 5 (23%) endotropy cases remained with an hypercorrection of 10 dp; and 2 (4.1%) exotropy cases had residuals below 15 dp (<span class="elsevierStyleBold">Table 2</span>).</p><p class="elsevierStylePara"><img src="321v85n04-90090758fig2.jpg" alt="¿ Table 2. Mean comparison of strabismus angle following a second application of botulinum toxin. "></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Results by MR:</span> After 2 months, in the endotropy group the best responses were observed in 2 children with mild MR: 75 dp of correction. After 12 months, the mean correction was 15 dp in patients with mild and moderate MR. The worst results were observed in children with severe MR; in this group, 27 dp corrections were observed after 2 months, and after 12 months the mean correction was 9 dp. In the retreatment cases, we observed a significant less response and regression to the original strabismus, especially in children with severe MR.</p><p class="elsevierStylePara">All the patients from the exotropy group had moderate, severe and profound MR. At the 2 and 4 month follow up, there was no difference in the response. But at the 12<span class="elsevierStyleSup">th</span> month follow up they had a mean correction of 6.6 dp. The retreatment cases received a 2<span class="elsevierStyleSup">nd</span> dose observing a minimum response; and at the 4<span class="elsevierStyleSup">th</span> month after retreatment these cases returned to their original strabismus. Exotropy group: all the patients had moderate, severe and profound RM. At the 2<span class="elsevierStyleSup">nd</span> and 4th month follow up there was no significant differences in the outcomes. The correction of 6.6 dp was achieved until 12 months. The retreatment cases received a 2<span class="elsevierStyleSup">nd</span> dose with a minimum response, and after the 4<span class="elsevierStyleSup">th</span> month all of them regress to the original strabismus (<span class="elsevierStyleBold">Figure 1</span>).</p><p class="elsevierStylePara"><img src="321v85n04-90090758fig3.jpg" alt="¿ Figure 1. Mental retardation and strabismus. "></img></p><p class="elsevierStylePara">¿ <span class="elsevierStyleBold">Figure 1</span>. Mental retardation and strabismus. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Response by degree of functional disability:</span> in the endotropy group the best outcomes were observed in the mild cases and the worst corrections in the severe ones, with 18 <span class="elsevierStyleItalic">vs.</span> 8 dp. In the exotropy group the mean correction was 5 dp. The response tendency to retreatment was significantly less in the exotropy group (<span class="elsevierStyleBold">Figure 2</span>).</p><p class="elsevierStylePara"><img src="321v85n04-90090758fig4.jpg" alt="¿ Figure 2. Strabismus and severity of the cerebral injury."></img></p><p class="elsevierStylePara">¿ <span class="elsevierStyleBold">Figure 2</span>. Strabismus and severity of the cerebral injury.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Response by type of injury:</span> of the 34 patients with spastic PCP, 17 had endotropy and 17 had exotropy. Their outcome was: for the endotropy group the mean angle of correction was 38 dp after 2 months, 15 (88%) of them archived a correction of 37 dp making them successful cases. After 4 months they regressed to a residual mean of 18 dp and after 1 year to 28 dp. In the exotropy group the correction angle was 42 dp. After 2 months the correction was 19 dp and after 4 months and up to 1 year, all of them regressed to 34 dp. Arranged by frequency, the 4 patients with hypotonic PCP had exotropy with a correction angle of 31 dp; after 2 months the angle decreased to 16 dp, after 4 months 18 dp and after 1 year 37 dp (none of them were successful cases). Of the 3 children with dyskinetic PCP, 2 of them had endotropy and 1 exotropy. The endotropy group had an initial angle of 25 dp; after 2 months they achieved a hypercorrection of up to 33 dp, after 4 months they regressed to 20 dp and after 1 year they had a residual mean of 30 dp. The only exotropy patient with an initial angle of 60 dp underwent just one post-treatment follow up after 4 months with a residual of 40 dp. Of the 2 children with ataxic PCP, 1 had endotropy and 1 exotropy. In both cases the initial angle was 32 dp and after 2 months the endotropy had an hypercorrection of 35 dp and normal position after 4 months. Finally, of the 2 patients with mixed PCP, 1 had endotropy and 1 exotropy respectively; with the endotropy angle (35 dp) being higher than the exotropy (20 dp). After 2 months the endotropy was no corrected. After 4 months it was not corrected. After 6 months with 35 dp, it was reinjected. An after 1 year it archived -10dp. The exotropy had an initial hypercorrection of 10 dp, regressing to the initial angle after 4 months and to a residual of 20 dp after 1 year (<span class="elsevierStyleBold">Figure 3</span>).</p><p class="elsevierStylePara"><img src="321v85n04-90090758fig5.jpg" alt="¿ Figure 3. Strabismus and type of cerebral palsy. "></img></p><p class="elsevierStylePara">¿ <span class="elsevierStyleBold">Figure 3</span>. Strabismus and type of cerebral palsy. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Results by visual acuity:</span> 23 (51%) patients had normal vision (mean age 6 years old); 15 (33%) had subnormal vision (mean age 10 years old) and 7 (16%) had severe visual deterioration (the smallest children). In the patients with normal vision we had 4 successful cases after 1 year with corrections of up to 35 dp (all of them had endotropy). In the subnormal vision group we had 3 successful cases, and among the severe group we only had 2 successful cases. During retreatment, we had 2 successful cases among the normal vision group with corrections of up to 50 dp after 1 year of follow up. In the subnormal vision group we only had 1 endotropy case that achieved a correction of 45 dp after 1 year of treatment. None of the patients with severe deterioration were successful (<span class="elsevierStyleBold">Figure 4</span>). </p><p class="elsevierStylePara"><img src="321v85n04-90090758fig6.jpg" alt="¿ Figure 4. Strabismus and visual acuity."></img></p><p class="elsevierStylePara">¿ <span class="elsevierStyleBold">Figure 4</span>. Strabismus and visual acuity.</p><p class="elsevierStylePara">From the ethyology point of view, the most frequent cases<span class="elsevierStyleSup">15</span> were the children with history of perinatal asphyxia, where 62% of them had exotropia and 56% had subnormal vision with severe deterioration. The second cause was prematurity in 15 cases; where 66% of them had endotropy, 46% with subnormal vision and severe deterioration. The third place with 4 cases went to the infectious diseases; 75% with exotropy, 50% with subnormal vision and severe deterioration. The smallest frequency was represented by postnatal accidents as well as genetic and congenital disorders. </p><p class="elsevierStylePara">We also had 2 cases of consecutive exotropy in children with spastic PCP and severe MR after 1 year of retreatment. Some of the secondary effects seen are: transitory ptosis with spontaneous resolution during the 2 first weeks and subconjunctival hemorrhage. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ Discussion</span></p><p class="elsevierStylePara">Strabismus associated with PCP represents a problem for the motor and sensory diagnosis, particularly in those patients that also have systemic complications that endanger their lives and intellectual development. Therefore we must not delay the strabismus treatment and treat patients with advance deterioration of the motor and sensory eye functions. Previous studies show that the surgical treatment of these patients has uncertain results due to the neurologic instability secondary to the cerebral injury, the compromise of the cortical and subcortical control centers and the poor fusion potential; all of these lead to hypercorrections.<span class="elsevierStyleSup">2,4</span> Surgical treatment has been substituted by the BT in these patients, and its effectiveness and innocuousness has been demonstrated in neurological healthy patients and those with cerebral injury secondary to diagnosis different to cerebral palsy and in those with systemic diseases where there is a high risk during the anesthetic procedure.<span class="elsevierStyleSup">2,3</span></p><p class="elsevierStylePara">Strabismus is very frequent in patients with cerebral injury. According to several studies the frequency range is 30% to 80%. In our center, 60% of the patients with PCP have some type of strabismus. We agree with the results published by Arroyo Yllanes, who reports that quadriparesia is more frequent (75%), while in our center we have a 77%. The author reports the spastic type as the more frequent (67%). We agree with a higher percentage (75%).16,17 Another important fact in the published work of the above mentioned author is that there is no correlation between the type and the severity of the PCP with the type of strabismus. However, we can say that the exotropy does have a relationship with the hypotonic type and severe PCP. A clinical element that is particularly important is the variation of the deviation angle.<span class="elsevierStyleSup">4,16</span> In our work, we did not take it into account for the determination of the result. However, we did treat strabismus cases with angle variation and the biggest angle was taken into consideration. Several published studies mix up patients with different types of cerebral injury. We only included patients with diagnosis of PCP in an effort to homogenize our study group. As a comparison, we can mention the results according to the type of strabismus published by Moguel, where the endotropy group had a 69% rate of success<span class="elsevierStyleSup">4</span> and Arroyo Y had a 31% rate of success<span class="elsevierStyleSup">8</span> when compared with the 38.1% of our group in the long run. For the exotropy group Moguel reports a 40% rate of success<span class="elsevierStyleSup">4,5</span> compared with the 16.6% in our cases and pointing out as successful patients those within a residual of 15 dp. The difference in the success rate is very obvious, above all among the published results of neurological healthy children, as in the Gómez de Liaño study where the success rate was between 66% and 76% in the endotropy group with a residual of 10 dp.<span class="elsevierStyleSup">18,19</span> It is likely that our evaluation criteria for a good result was strict, because if we add the outcomes where the residual deviations were within 15 dp, the percentage goes up to 84.2% in the endotropy group and 42.1% in the exotropy group after 2 months. In our study series we found 2 (9.5%) cases of consecutive exotropy, that Arroyo Y. and collaborators also points out in 25% their cases<span class="elsevierStyleSup">8</span> and Tejedor and collaborators in 0.3% of their 2245 patients treated for endotropy;<span class="elsevierStyleSup">20</span> all them needed surgical correction after 1 year of treatment with BT. The possible contributing factors to this result could have been the high dose of toxin and the bad sensory status. In our patients, we observed this after the second application; therefore we can attribute it to an excessive dose. It is possible that the consecutive exotropy in children with psychomotor delay is the result of multiple factors, among them the bad development of the centers of binocular cortical integration, convergence insufficiency and reinjection. Even though the treatment success outcomes of strabismus in children with PCP are not encouraging, we agree with Keith W McNeer<span class="elsevierStyleSup">21,22</span> in that one of the most important factor in strabismus treatment is to maintain a good eye alignment as long as possible during the visual development period. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ Conclusion</span></p><p class="elsevierStylePara">In the short term, the BT is effective in PCP with endotropy, showing a high rate of success after 2 and 4 months of treatment. But in the long run it had a low rate of success if we only consider the size of the deviation angle. However, we can consider that the children with mild cerebral injury and a lower degree of MR with small to medium entropy angles have a better response even with a history of prematurity. </p><p class="elsevierStylePara">The BT is not effective in the long run for PCP with exotropy. However, we did see a decrease of the deviation angle after 2 months of treatment with a tendency to return to the original strabismus. These are associated with severe and profound MR and severe visual deterioration.</p><p class="elsevierStylePara">Even though it was not statistically significant, we can establish a relationship between the hypotonic PCP cases with great exotropy and the worst results.</p><p class="elsevierStylePara">We consider that the failures in the endotropy and exotropy groups are due to the poor fusion potential of the children with cerebral injury.</p><p class="elsevierStylePara">The children with better vision (in the endotropy and exotropy groups) have a better response to the first application and did not show differences in the following one. Therefore, the first application of BT decides the response to treatment. </p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleBold">Corresponding author:</span> Copal 4575, frac. Arboledas del Sur, Guadalajara Jalisco México C.P. 44980. <br></br> Phone: 33 31342552, fax: 33 31342525. <br></br> E-mail address: <a href="mailto:isegura@teleton-occ.org.mx" class="elsevierStyleCrossRefs">isegura@teleton-occ.org.mx</a></p>" "pdfFichero" => "321v85n04a90090758pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec179449" "palabras" => array:1 [ 0 => "Endotropia, exotropia, parálisis cerebral, retraso mental, toxina botulínica, México" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec179450" "palabras" => array:1 [ 0 => "Endotropy, exotropy, cerebral palsy, mental retardation, botulinum toxin, Mexico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "Objetivo: Evaluar la eficacia de la toxina botulínica en el tratamiento de estrabismo en pacientes con parálisis cerebral infantil. Métodos: Estudio prospectivo, en niños con parálisis cerebral infantil y estrabismo horizontal. Tratados con toxina botulínica en músculos rectos horizontales, evaluados a los 0, 2, 4 y 12 meses, se midió la respuesta según coeficiente intelectual, tipo de estrabismo, lesión cerebral e invalidez funcional. Resultados: Fueron tratados 45 niños de 1-18 años. 21 con endotropia ángulo promedio 35 dioptrías prismáticas, a 2, 4 y 12 meses resultaron con -3.8, 16.5 y 24 dioptrías respectivamente (p <0 001 veinticuatro niños con exotropia promedio 39 dioptrías a dos cuatro y 12 meses tuvieron ángulos de 3 27 7 30 respectivamente p <0 001 las mejores respuestas fueron correcciones hasta de 75 dioptrías en pacientes con endotropia y retraso mental leve peores exotropia profundo cuadriparesia espástica severa conclusiones: la toxina botulínica es efectiva a largo plazo los parálisis cerebral el resultado proporcional al coeficiente intelectual severidad del daño neurológico asociada mayor lesión no tiene buenos resultados ni aún más una aplicación " ] "en" => array:1 [ "resumen" => "Objective: To evaluate the efficacy of botulinum toxin in the treatment of strabismus in pediatric patients with cerebral palsy. Methods: prospective study in patients with cerebral palsy and horizontal strabismus. Treated with botulinum toxin applied into the horizontal rectus muscles evaluated at 0, 2, 4 and 12 months. The response was measured according to IQ score, type of strabismus, and degree of functional disability. Results: 45 children from 1 to 18 years, 21 with endotropy mean angle of 35 prismatic dioptres were treated. At the 2, 4 and 12 month all of them achieved 3.8, 16.5 and 24 dioptres respectively (p <0 001 24 children with a mean exotropy of 39 dioptres achieved angles 12 3 27 7 y 30 p <0 001 the best responses were corrections of up to 75 dioptres in patients with endotropy and mild mental retardation worst observed exotropy severe deficiency spastic quadriparesia conclusions: botulinum toxin is effective cerebral palsy proportional iq score severity injury when associated greater we did not achieve good results even more than one application " ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig1.jpg" "Alto" => 479 "Ancho" => 1945 "Tamanyo" => 138349 ] ] "descripcion" => array:1 [ "en" => "¿ Table 1. Mean comparison of strabismus angle following a single application of botulinum toxin." ] ] 1 => array:7 [ "identificador" => "fig2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig2.jpg" "Alto" => 487 "Ancho" => 1945 "Tamanyo" => 137758 ] ] "descripcion" => array:1 [ "en" => "¿ Table 2. Mean comparison of strabismus angle following a second application of botulinum toxin." ] ] 2 => array:7 [ "identificador" => "fig3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig3.jpg" "Alto" => 554 "Ancho" => 916 "Tamanyo" => 67731 ] ] "descripcion" => array:1 [ "en" => "¿ Figure 1. Mental retardation and strabismus." ] ] 3 => array:7 [ "identificador" => "fig4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig4.jpg" "Alto" => 550 "Ancho" => 900 "Tamanyo" => 66839 ] ] "descripcion" => array:1 [ "en" => "¿ Figure 2. Strabismus and severity of the cerebral injury." ] ] 4 => array:7 [ "identificador" => "fig5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig5.jpg" "Alto" => 595 "Ancho" => 937 "Tamanyo" => 68916 ] ] "descripcion" => array:1 [ "en" => "¿ Figure 3. Strabismus and type of cerebral palsy." ] ] 5 => array:7 [ "identificador" => "fig6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "321v85n04-90090758fig6.jpg" "Alto" => 566 "Ancho" => 962 "Tamanyo" => 66355 ] ] "descripcion" => array:1 [ "en" => "¿ Figure 4. Strabismus and visual acuity." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Terminology and classification of cerebral palsy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Bax MCO." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Dev Med Child Neurol 1964" "volumen" => "6" "paginaInicial" => "295" "paginaFinal" => "307" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Assessment of visual acuity in multiply handicapped children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Mackie RT" 1 => "Mc Culloch DL." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Br J Ophthalmol 1995" "volumen" => "79" "paginaInicial" => "290" "paginaFinal" => "296" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Scott AB." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Ophthalmology 1980" "volumen" => "87" "paginaInicial" => "1044" "paginaFinal" => "1049" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Treatment with botulinum toxin for strabismus with psychomotor delay." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Moguel-Ancheita S" 1 => "Martínez-Oropeza S" 2 => "Orozco-Gómez LP." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Arch Soc Esp Oftlamol 2004" "volumen" => "79" "paginaInicial" => "443" "paginaFinal" => "448" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Usefulness of botulinum toxin for strabismus treatment in systemic diseases." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Moguel-Ancheita S" 1 => "Dixon-Olvera S" 2 => "Martínez-Oropeza S" 3 => "Orozco-Gómez LP." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Arch Soc Esp Oftalmol 2003" "volumen" => "78" "paginaInicial" => "9" "paginaFinal" => "14" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Binocular depth perception of computer-generated patterns." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Julesz B." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Bell System Technical J 1960" "volumen" => "39" "paginaInicial" => "1125" "paginaFinal" => "1162" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin therapy of eye muscle disorders: safety and effectiveness." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "McNeer KW." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Ophthalmol 1989" "volumen" => "2" "paginaInicial" => "37" "paginaFinal" => "41" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin application outcomes in patients with endotropy and psychomotor delay." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Arroyo-Yllanes ME" 1 => "Pérez-Pérez JF" 2 => "Murillo-Murillo L." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Cir Ciruj 2009" "volumen" => "77" "paginaInicial" => "9" "paginaFinal" => "12" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin treatment for horizontal strabismus in children with cerebral palsy." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Cronemberger MF" 1 => "Mendonça TS" 2 => "Bicas HEA." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Arq Bras Oftalmol 2006" "volumen" => "69" "paginaInicial" => "523" "paginaFinal" => "529" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Correlating preferential looking visual acuity and visual behavior in severely visually handicapped children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Katsumi O" 1 => "Chedid SG" 2 => "Kronheim JK" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Acta Opthalmol Scand 1995" "volumen" => "73" "paginaInicial" => "407" "paginaFinal" => "413" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Blindness and visual acuity decrease." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "International Statistical Classification of diseases and Related Health Problems." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "fecha" => "Geneva OMS 1992" "volumen" => "435-6. Mental retardation 356-357" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Epidemiology of visual impairment and blindness in childhood Pediatric ophthalmology and strabismus, p." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Taylor D" 1 => "Creig S Hoyt." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "fecha" => "1, Chap 1, 3 edition 2005" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The binocular examination of The Young child." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Krimsky E." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "fecha" => "Am J Ophthalmol 1943" "volumen" => "1" "paginaInicial" => "624" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "International Statistical Classification of Functioning" 1 => "disability and Health" 2 => "Geneva: World Health Organization; 2001." ] ] ] ] ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin injection without electromyographic assistance." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Chipont E" 1 => "García P" 2 => "Arrazola MT" 3 => "Alió JL." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Pediatr Ophthalmol Strabism 2002" "volumen" => "39" "paginaInicial" => "231" "paginaFinal" => "5" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Comportamiento del estrabismo en la parálisis cerebral." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Arroyo-Yllanes ME" 1 => "Benítez-Nava A" 2 => "Garrido E." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Cir Ciruj 1999" "volumen" => "67" "paginaInicial" => "208" "paginaFinal" => "212" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cerebral palsy eye motility disturbances." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Arroyo-Yllanes ME" 1 => "Manzo-Villalobos G" 2 => "Pérez-Pérez J" 3 => "Garrido E." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Rev Mex Oftalmol 1999" "volumen" => "73" "paginaInicial" => "258" "paginaFinal" => "61" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Strabismus treatment with botulinum toxin." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Gómez-de-Liaño R" 1 => "Pérez-Santonja JJ" 2 => "Zato MA." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Arch Soc Esp Oftal 1991" "volumen" => "60" "paginaInicial" => "451" "paginaFinal" => "456" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin bimedial injection." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Gómez-de-Liaño R" 1 => "Rodríguez JM" 2 => "Ogallar C" 3 => "Zato MA." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Arch Soc Esp Estrabol 1991" "volumen" => "19" "paginaInicial" => "71" "paginaFinal" => "74" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Management of nonresolving consecutive exotropia following botulinum toxin treatment of childhood esotropia." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Tejedor J" 1 => "Rodríguez JM." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Arch Ophathalmol 2007" "volumen" => "125" "paginaInicial" => "1210" "paginaFinal" => "1213" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Management of essential infantile esotropia with botulinum toxin A: review and recommendations." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "McNeer KW" 1 => "Tucker MG" 2 => "Spencer RF." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Pediatr Ophthalmol Strabismus 2000" "volumen" => "37" "paginaInicial" => "63" "paginaFinal" => "67" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Botulinum toxin management of essential infantile esotropia in children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "McNeer KW" 1 => "Tucker M G" 2 => "Spencer RF." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "fecha" => "Archives of ophthalmology 1997" "volumen" => "115" "paginaInicial" => "1411" "paginaFinal" => "1418" "itemHostRev" => array:3 [ "pii" => "S014067360517826X" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/01874519/0000008500000004/v0_201306251234/X0187451911907580/v0_201306251235/en/main.assets" "Apartado" => array:4 [ "identificador" => "13779" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Artículos originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/01874519/0000008500000004/v0_201306251234/X0187451911907580/v0_201306251235/en/321v85n04a90090758pdf001.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0187451911907580?idApp=UINPBA00004N" ]
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ISSN: 01874519Original language: English
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| 2020 February | 11 | 5 | 16 |
| 2020 January | 19 | 19 | 38 |
| 2019 December | 15 | 9 | 24 |
| 2019 November | 4 | 11 | 15 |
| 2019 October | 19 | 8 | 27 |
| 2019 September | 14 | 6 | 20 |
| 2019 August | 7 | 2 | 9 |
| 2019 July | 18 | 6 | 24 |
| 2019 June | 45 | 19 | 64 |
| 2019 May | 100 | 20 | 120 |
| 2019 April | 41 | 9 | 50 |
| 2019 March | 5 | 2 | 7 |
| 2019 February | 11 | 3 | 14 |
| 2019 January | 7 | 4 | 11 |
| 2018 December | 11 | 2 | 13 |
| 2018 November | 7 | 6 | 13 |
| 2018 October | 12 | 9 | 21 |
| 2018 September | 11 | 4 | 15 |
| 2018 August | 10 | 4 | 14 |
| 2018 July | 9 | 2 | 11 |
| 2018 June | 15 | 0 | 15 |
| 2018 May | 15 | 1 | 16 |
| 2018 April | 2 | 0 | 2 |
| 2018 March | 8 | 1 | 9 |
| 2018 February | 6 | 0 | 6 |
| 2018 January | 7 | 0 | 7 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 8 | 1 | 9 |
| 2017 October | 6 | 0 | 6 |
| 2017 September | 6 | 1 | 7 |
| 2017 August | 9 | 7 | 16 |
| 2017 July | 14 | 0 | 14 |
| 2017 June | 19 | 13 | 32 |
| 2017 May | 24 | 2 | 26 |
| 2017 April | 13 | 6 | 19 |
| 2017 March | 12 | 29 | 41 |
| 2017 February | 17 | 2 | 19 |
| 2017 January | 6 | 1 | 7 |
| 2016 December | 13 | 4 | 17 |
| 2016 November | 11 | 1 | 12 |
| 2016 October | 12 | 4 | 16 |
| 2016 September | 12 | 1 | 13 |
| 2016 August | 9 | 1 | 10 |
| 2016 July | 10 | 2 | 12 |
| 2016 June | 34 | 8 | 42 |
| 2016 May | 34 | 10 | 44 |
| 2016 April | 22 | 10 | 32 |
| 2016 March | 28 | 13 | 41 |
| 2016 February | 32 | 13 | 45 |
| 2016 January | 25 | 16 | 41 |
| 2015 December | 26 | 15 | 41 |
| 2015 November | 26 | 11 | 37 |
| 2015 October | 23 | 12 | 35 |
| 2015 September | 24 | 6 | 30 |
| 2015 August | 22 | 11 | 33 |
| 2015 July | 19 | 2 | 21 |
| 2015 June | 14 | 7 | 21 |
| 2015 May | 18 | 6 | 24 |
| 2015 April | 17 | 8 | 25 |
| 2015 March | 31 | 7 | 38 |
| 2015 February | 23 | 1 | 24 |
| 2015 January | 28 | 4 | 32 |
| 2014 December | 63 | 6 | 69 |
| 2014 November | 38 | 5 | 43 |
| 2014 October | 45 | 4 | 49 |
| 2014 September | 38 | 5 | 43 |
| 2014 August | 29 | 3 | 32 |
| 2014 July | 38 | 4 | 42 |
| 2014 June | 46 | 1 | 47 |
| 2014 May | 45 | 1 | 46 |
| 2014 April | 23 | 1 | 24 |
| 2014 March | 32 | 2 | 34 |
| 2014 February | 39 | 1 | 40 |
| 2014 January | 25 | 2 | 27 |
| 2013 December | 39 | 2 | 41 |
| 2013 November | 53 | 1 | 54 |
| 2013 October | 51 | 3 | 54 |
| 2013 September | 26 | 4 | 30 |
| 2013 August | 50 | 3 | 53 |
| 2013 July | 27 | 1 | 28 |
| 2011 September | 702 | 0 | 702 |
Show all
