Botulinum toxin A (BTA) (Botox, Allergan; Dysport, Galderma; Xeomin, Merz Aesthetics)
Once an orphan drug, BTA demonstrated efficacy in the treatment of strabismus because of its ability to selective relax muscles and was subsequently used for various facial spasms and aesthetics, as well as pain and autonomic disorders.5,6
Recently, neurologists and ophthalmologists have been exploring BTA’s potential for treatment of neuropathic pain syndromes.7,8 Strategic injection of BTA also could produce any number of benefits to the ocular surface by addressing corneal allodynia and neuralgia of the ophthalmic branch of the trigeminal nerve.
In ophthalmology, BTA injections in young aesthetic patients can mitigate lateral canthal rhytids addressing decreased Schirmer’s testing and tear breakup time.9
Conversely, in patients with blepharospasm and concurrent DED, strategic injection at the lateral canthus and pretarsal orbicularis can improve symptoms and reduce inflammatory cytokine production.10
In refractory filamentary keratitis patients, a similar low-dose pre-tarsal injection technique was shown to resolve filaments in nearly 90% of patients.11 A single lower eyelid injection medial to the punctum can weaken the Horner’s muscle, reducing tear drainage by approximately 40%.12
This technique also increases post-LASIK patient satisfaction by reducing lubricant dependency, with fewer complications than silicone punctal plugs.13 Injections in the lacrimal gland have helped patients with epiphora due to hyperreflexive lacrimation.14 Lastly, injected specifically to induce ptosis, BTA can offer a temporary tarsorraphy to protect the ocular surface.
1. Liu R, Rong B, Tu P, et al. Analysis of Cytokine Level in Tears and Clinical Correlations After Intense Pulsed Light Treating Meibomian Gland Dysfunction. AJO. 2017 Nov;183: 81-90.
2. Craig JP, Chen YH, Turnbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015 Feb 12;56(3):1965-70.
3. unpublished data
4. Yin Y, Liu N, Gong L, Song N. Changes in the Meibomian Gland After Exposure to Intense Pulsed Light in Meibomian Gland Dysfunction (MGD) Patients. cure Eye Res. 2018 Mar;43(3): 308-313.
5. Scott AB, Miller JM, Shieh KR. Treating Strabismus by Injecting the Agonist Muscle with Bupivacaine and the Antagonist with Botulinum Toxin. Trans Am Ophthalmol Soc. 2009 Dec;107:104-109.
6. Romanov A, Pokushalov E, Ponomarev D, et al. Long-term suppression of atrial fibrillation by botulinum toxin injection into epicardial fat pads in patients undergoing cardiac surgery: Three-year follow-up of a randomized study. Heart Rhythm. 2019 Feb;16(2):172-177.
7. Park J, Park HJ. Botulinum Toxin for the Treatment of Neuropathic Pain. Toxins (Basel). 2017 Sep; 24;9(9):260.
8. Diel RJ, Kroeger ZA, Levitt RC, et al. Botulinum Toxin A for the Treatment of Photophobia and Dry Eye. Ophthalmology. 2018 Jan; 125(1): 139–140.
9. Ho MC, Hsu WC, Hsieh YT. Botulinum Toxin Type A Injection for Lateral Canthal Rhytids. JAMA Ophthalmol. 2014;132(3):332-337.
10. Lu R, Huang R, Li K, et al. The influence of benign essential blepharospasm on dry eye disease and ocular inflammation. Am J Ophthalmol. 2014 Mar;157(3):591-7.e1-2.
11. Gumus K, Lee S, Yen MT, Pflugfelder SC. Botulinum toxin injection for the management of refractory filamentary keratitis. Arch Ophthalmol. 2012 Apr;130(4):446-50.
12. Sahlin S, Chen E, Kaugesaar T. Effect of eyelid botulinum toxin injection on lacrimal drainage. Am J Ophthalmol. 2000 Apr;129(4):481-6.
13. Fouda SM, Mattout HK. Comparison Between Botulinum Toxin A Injection and Lacrimal Punctal Plugs for the Control of Post-LASIK Dry Eye Manifestations: A Prospective Study. Ophthalmol Ther. 2017 Jun;6(1):167-174.
14. Singh S, Ali MJ, Paulsen F. A review on use of botulinum toxin for intractable lacrimal drainage disorders. Int Ophthalmol. 2018 Oct;38(5):2233-2238.
15. Mérida S, Palacios E, Navea A, Bosch-Morell F. New Immunosuppressive Therapies in Uveitis Treatment. Int J Mol Sci. 2015 Aug 11;16(8):18778-95.
16. Goldberg RA, Lee S, Jayasundera T, et al. Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic Acid gel. Ophthalmic Plast Reconstr Surg. 2007 Sep-Oct;23(5):343-8.
17. Mancini R. Managing eyelid malpositions with hyaluronic acid gel injections. Int Ophthalmol Clin. 2013 Summer;53(3):11-20.