Adam R. Sweeney, Christopher R. Dermarkarian, Katherine J. Williams, Richard C. Allen & Michael T. Yen
Purpose: To report the efficacy of polytetrafluoroethylene (PTFE) frontalis suspension for blepharospasm with eyelid apraxia and postoperative botulinum toxin requirements.
Methods: Retrospective chart review of patients with blepharospasm and eyelid apraxia who underwent frontalis suspension. The primary outcome was a surgical success, defined by surgeon- and patient-reported success in postoperative eyelid opening. Comparative statistical analyses of botulinum toxin dosage and treatment intervals were performed amongst patients before and after frontalis suspension ptosis repair.
Results: Five patients (10 eyelids) met the study criteria, of which 40% were female. Mean age was 63.2 years. All patients had successful surgical outcomes based on physician-reported and patient reported satisfaction with the postoperative eyelid opening. Average follow-up was 14 months. Preoperative botulinum toxin treatments averaged 80.4 units (range 32–110, SD 33.2) to the periocular region over an average of 9.6-week intervals. Postoperative botulinum toxin treatments averaged 61.4 units (range 24–110, SD 34.7) to the periocular region over an overage of 9.8-week intervals. No patients experienced postoperative exposure keratopathy, extrusion of the sling, or postoperative infection.
Conclusions: Frontalis suspension using PTFE suture in the setting of blepharospasm with eyelid apraxia was found to be a safe and effective procedure. Frontalis suspension in this population is not a substitute for botulinum toxin treatment but may allow for reduced treatment dosage. Frontalis suspension appears to increase patient functionality with improved eyelid opening in patients with blepharospasm with eyelid apraxia.
Trakos, Nikolaos; Singh, Swati; Mishra, Dilip Kumar; Ali, Mohammad Javed
To investigate the histopathological and ultrastructural changes in the lacrimal glands (LGs) of rabbits following either botulinum toxin (BTX) injection or simple glandular needling.
Twenty-four LGs of 24 eyes of 12 healthy New Zealand white rabbits were included in the study. Of these, 4 LGs of 4 eyes of 2 rabbits were used as controls. In the intervention group, all the right LG received 5 U in 0.1 ml of BTX-A (Botox, Allergan, Dublin, Ireland) and the left LG received simple glandular needling under general anesthesia. The BTX-A was injected directly into the LG via the transconjunctival route under direct visualization. For simple needling, 5 LG passes were made through a single-entry point using a 29-gauge needle mounted on an empty tuberculin syringe. The rabbits did not receive any postoperative medications other than lubricants. The rabbits were sacrificed at 8 weeks and the 20 treated and 4 control LG’s were retrieved for histopathological and transmission electron microscopic (TEM) analysis as per standard protocols.
In comparison to the control LG samples, both the treated groups showed pathological changes, which were more pronounced in the simple needling group. The BTX-A-treated LGs showed mild to moderate acinar atrophy, few degenerating acini and patchy chronic inflammatory infiltrates with thick hyalinized collagen within the glandular stroma. TEM analysis showed the cytosol of few acinar cells to contain vacuoles and autophagosomes with marginal chromatin condensation of the nucleus and an eccentric nucleolus. The LGs treated with simple needling showed marked pathological changes which include moderate to severe, focal, and diffuse acinar atrophy, dense stromal fibrosis, inflammatory infiltrates, and peri-vasculitis. TEM analysis showed focal disorganized acinar morphology, loss of intra-acinar and ductal architecture, and needle track zones with surrounding fibrotic areas.
Histopathological and ultrastructural changes were noted in the LGs treated with BTX-A and simple glandular needling. Simple needling of the LG has the prospect to be an effective and cheaper alternative to BTX-A.
Amun Sachdev, Declan Costello & Simon Madge
In ophthalmology, there have been few reports of botulinum toxin type-A (BTX-A) injection into the lacrimal gland to treat epiphora. In ENT, adductor and abductor (ABSD) spasmodic dysphonia are often treated with BTX-A injections into the respective overacting vocal cord muscles. We describe a 53-year old male with Parkinson’s disease who did not respond to BTX-A injections to either the lacrimal gland, for epiphora secondary to Parkinsonian-related blink lagophthalmos, or posterior cricoarytenoid (PCA) muscles for ABSD. Subsequent BTX type-B (BTX-B) injections into the lacrimal gland remarkably improved his epiphora. BTX-B injections into the PCA muscle also greatly improved his dysphonia. We describe the first reported case of (1) BTX-B injection into the lacrimal gland for epiphora, (2) use of Botox in treating epiphora due to blink lagophthalmos/reduced blink frequency secondary to Parkinson’s disease, (3) BTX-B use in treating ABSD, and (4) association between ABSD and Parkinson’s disease.
Min Gyu Choi, Joon Hyung Yeo, Jeong Woo Kang, Yeoun Sook ChunJeong Kyu LeeJae Chan Kim
To determine the effects of botulinum toxin type A (BTX-A) injection on dry eye signs, symptoms, and tear cytokine levels in patients with intractable dry eye disease (DED).
In this prospective study, patients with intractable DED were randomized to a BTX-A (group A) or control group (group B). Patients were injected with BTX-A or normal saline in the medial part of the upper and lower eyelids. Before and at 2 weeks, 1 month, 2 months, and 4 months after injection, dry eye signs; tear film break-up time (TBUT), Schirmer I test, corneal fluorescein staining (CFS), and symptoms; ocular surface disease index (OSDI); and frequency of lubricants were assessed. The tear levels of matrix metalloproteinase (MMP)-9 and serotonin were measured before and at 1 month after injection.
Fifty-two eyes from 26 patients (mean age, 57.7 years) were included. The TBUT was higher at 2 weeks and at 1 month in group A. The Schirmer I test and OSDI scores were also better in group A for up to 2 months. The CFS grades in group A were significantly lower until 4 months. Repeated measures analysis of variance (RMANOVA) demonstrated significant differences between the two groups over time for the Schirmer I test (p = 0.002), CFS (p = 0.025), OSDI (p = 0.020), and frequency of lubricants (p = 0.029). The MMP-9 conversion rate of group A (76.92%) was significantly higher than that of group B (38.46%, p = 0.005). The tear serotonin level in group A was reduced from 2.76 ± 0.34 to 1.73 ± 0.14 ng/mL (p < 0.001). No complications were observed during the study.
BTX-A injection into the medial part of eyelid improves dry eye signs and symptoms and reduces tear cytokine levels. BTX-A is thus a potential treatment option for patients with intractable DED.
Swati Singh, Mohammad Javed Ali, Friedrich Paulsen
To review the published literature on botulinum toxin (BTX) for epiphora secondary to refractory lacrimal drainage disorders.
The authors performed a Pub Med search of all articles published in English on BTX injection into lacrimal gland for epiphora secondary to lacrimal drainage disorders. Relevant cross-references were obtained from the resultant studies. Data reviewed included demographics, indications, dose of BTX, number of injections, transconjunctival or transcutaneous route, outcomes and complications. Animal experiments of BTX into lacrimal gland were included and analyzed separately.
Botulinum toxin injection into lacrimal gland, in animal studies, has shown to reduce the tear volume significantly lasting for approximately a month without any histological changes. The major indications have been refractory canalicular obstructions and functional epiphora. The commonly used dose was 2.5 U. Outcomes in the few studies published are encouraging with transient ptosis being the most common complication.
Botulinum toxin into the lacrimal gland is a minimally invasive alternative in cases of refractory epiphora secondary to lacrimal drainage disorders. In these subsets of patients, the reported concentrations, dosage and outcome measures are variable and need larger studies for standardization.
Jurij R. Bilyk, MD, Michael T. Yen, MD, Elizabeth A. Bradley, MD, Edward J. Wladis, MD, Louise A. Mawn, MD
To review the medical literature on the outcomes and complications of various Food and Drug Administration-approved botulinum toxins for benign essential blepharospasm (BEB) and hemifacial spasm (HFS).
Literature searches were last conducted in February 2017 in PubMed for articles published in English and in the Cochrane Library database without language limitations; studies published before 2000 were excluded. The combined searches yielded 127 citations. Of these, 13 articles were deemed appropriate for inclusion in this assessment, and the panel methodologist assigned ratings to them according to the level of evidence.
A combined total of 1523 patients (1143 with BEB and 380 with HFS) were included in the 13 studies. Five studies provided level I evidence, 2 studies provided level II evidence, and 6 studies provided level III evidence. Pretarsal injections were more efficacious than preseptal injections (96% vs. 86%, respectively). Pretarsal injections also resulted in a higher response rate on clinical scales (P < 0.05) and a longer duration of maximum response for both HFS and BEB. Patients with HFS require lower overall doses of onabotulinumtoxinA than patients with BEB for a similar duration of effect. Adverse events were dose related, and they occurred more frequently in patients who were given more units.
Level I evidence supports the efficacy of Botox (Allergan Corp., Irvine, CA), Meditoxin, and Xeomin (Merz Pharmaceuticals, Frankfurt am Main, Germany) for the treatment of BEB. Meditoxin and Botox have equivalent effectiveness and incidence of adverse events for BEB and HFS. Dysport (Ipsen Biopharmaceuticals, Inc, Paris, France) seems to have efficacy similar to Botox and Meditoxin for BEB and HFS, but any definitive conclusions from the 2 level II studies in this review are limited by differences in the methodologies used. Higher doses of Botox and Dysport result in more adverse events. Repeated treatments using Botox seem to maintain efficacy for treatment of facial dystonias over a follow-up period of at least 10 years, based on level III evidence.
Bo Young Chun, Su Yeon Kim
Acute visual loss after facial injection of cosmetic materials is rarely reported. In this study, we report one patient who developed acute visual loss after an injection of botulinum toxin A for esthetic purposes.
A 43-year-old Korean woman presented with a decrease in visual acuity to 20/800 after an injection of botulinum toxin A in the masseter muscle. The visual field testing showed an inferior altitudinal defect, and fluorescein angiography revealed a delayed arm-retinal circulation time.
After intravenous and oral prednisolone was administered, the patient’s visual acuity gradually improved. Two months after the botulinum toxin A injection, the visual acuity had almost returned to baseline, with a remaining paracentral scotoma.
This is the first case of acute visual loss following an injection of botulinum toxin A in a facial lesion. This case emphasizes that the potential risks of botulinum toxin A injection should be considered, and the procedure should be performed delicately.
Purvasha Narang, Swati Singh, Vikas Mittal
Botulinum toxin A (BTA) injections into lacrimal gland are being used for refractory epiphora due to intractable lacrimal disorders with success rates reported from 18% to 86%. Most common side effects are transient ptosis and diplopia. We report a case of a 59-year-old female injected with 2.5 units of BTA injection in each lacrimal gland for functional epiphora. The patient had a history of herpes simplex viral keratitis that was quiescent for more than 2 years. After 3 weeks, she developed reactivation of viral keratitis bilaterally, which was successfully managed with antivirals and topical steroids. Reactivation of quiescent herpes simplex keratitis is a possibility after lacrimal gland BTA and caution should be exercised in such cases.
Eldad Silberstein, MD Ehud Maor, MD Oleg Sukmanov, MD Alexander Bogdanov Berezovsky, MD, PhD Yaron Shoham, MD Yuval Krieger, MD
Muscle activity contributes to the enhancement of facial aging deformity, blepharospasm, cerebral palsy spasticity, trismus, torticollis, and other conditions. Myotomy of the involved muscles in order to reduce the deformity has variable success rates due to muscle healing and regeneration of activity.
The goal of this study was to investigate whether blocking striated muscle activity with Botulinum toxin (BtxA) during the healing time after myotomy alters the healing process and reduces long-term muscle activity.
Eighteen Sprague Dawley rats where divided into 3 groups: group A (n = 7) underwent myotomy of their Latisimus Dorsi muscle; group B (n = 7) underwent myotomy and injection of BtxA into their severed muscle; group C (n = 4) injection of BtxA only. Muscle strength was tested periodically using a grip test.
Starting at week 16 and until the termination of study at week 22, group B (Myotomy + BtxA) showed significant reduction in muscle power compared to the two control groups.
Addition of BtxA injection into a muscle immediately after myotomy may interfere with muscle healing and contribute to a more successful long-term result.
Ryan J. Diel, Zachary A. Kroeger, Roy C. Levitt, Constantine Sarantopoulos, Heather Sered, Jasmine Martinez-Barrizonte, Anat Galor
Photophobia is a chronic debilitating condition that, in severe cases, causes individuals to become prisoners in their own homes. Despite diminishing quality of life, few studies have evaluated therapies for photophobia. Anecdotally, botulinum toxin A (BoNT-A) was reported effective in the treatment of 3 patients with medication-refractory photophobia.1 In this cross-sectional retrospective study, we evaluate the effect of BoNT-A on photophobia and dry eye symptoms in individuals with chronic migraine (CM) and evaluate factors predictive of a positive treatment response.