—We thank Drs Lee and Olver for their comments regarding our case report. They bring up three points. First, they note that the botulinum toxin injection was unlikely to contribute to anterior segment ischemia. While we acknowledge their assumption, it remains as yet unproved. As stated in our report, it is possible that several factors may contribute to ischemia in addition to the transposition procedure.Their second point relates to the timing of the injection. They offer their rational for administering botulinum toxin prior to the muscle transposition. We believe that the injection can be administered with equal precision either before or in combination with the muscle transposition. Whether the timing of the injection has any effect on the long-term ocular alignment or the incidence of anterior segment ischemia is unknown.The third point is that vertical rectus surgery alone may result in anterior segment ischemia. We agree
Keech RV, Morris RJ, Ruben JB, Scott WE. Anterior Segment Ischemia Following Vertical Muscle Transposition and Botulinum Toxin Injection-Reply. Arch Ophthalmol. 1991;109(2):174. doi:10.1001/archopht.1991.01080020020007
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