Effect of eyelid botulinum toxin injection on lacrimal drainage

Surgical Procedures in the Treatment of Dry Eye Disease

Dry eye disease (DED) is a multifactorial disease affecting 5% to 50% in different populations. The most severe cases of DED are often caused by aqueous deficient dry eye disease (ADDE) due to lacrimal gland (LG) hypofunction. Many patients with severe ADDE do not experience adequate symptom relief from topical treatment, severely reducing their quality of life. The focus of this review is to describe the surgical interventions presently being used or investigated when topical treatment with eye drops is insufficient. The conventional surgical approach is to proceed to punctal occlusion or partial or total tarsorrhaphy. However, novel surgical procedures have been reported to have higher efficacy and patient satisfaction than conventional treatments. These procedures include amniotic membrane transplantation, transposition or transplantation of the salivary glands, and cell-based injections into the LG, each with strengths and weaknesses. Further development of these treatment modalities might prove pivotal in treating dry eye patients in the future.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

Evaluating the topographical measurements and tear function status in patients with hemifacial spasm: A comparative fellow eye study

OBJECTIVE

To investigate the effect of eyelid spasm on corneal and tear film characteristics in patients with hemifacial spasm (HFS) and compare these data with those of the contralateral eyes of the same patients.

METHODS

This prospective study is comprised of 64 eyes of 32 HFS patients, 32 eyes on the spasm side (Group 1) and 32 contralateral eyes (Group 2). Corneal tomographic analyses were performed; corneal power of flat axis (K1) and steep axis (K2), astigmatism and thinnest pachymetry; anterior, posterior and total corneal aberrometry [spherical aberration (SA), vertical coma (vcoma), horizontal coma (hcoma), total higher order aberration (THOA) and total RMS], and corneal densitometry values were evaluated and compared between groups. Tear meniscus height and depth (TMH, TMD) were measured using anterior segment optic coherence tomography. Tear function tests including TMH and TMD, the Schirmer I test, and tear break-up time (TBUT) were compared between the groups.

RESULTS

K1, K2, astigmatism and corneal densitometry values were similar between groups (p > 0.05). Thinnest pachymetry values were significantly thinner on the spasm side (p = 0.040). Anterior and total corneal SA and RMS were significantly higher on the spasm side (p = 0.032, p = 0.005; p = 0.015, p = 0.006, respectively). TMH, TMD and TBUT were significantly lower in Group 1 (p = 0.01, p = 0.02 and p = 0.03, respectively). Schirmer I test values were similar between groups (p > 0.05).

CONCLUSION

In HFS patients, there are changes in corneal parameters and tear film in the eye on the spasm side compared to unaffected eye.

Complications and Adverse Effects of Periocular Aesthetic Treatments

The popularity and variety of temporary and permanent periocular aesthetic treatments has increased over the past decade. Patients frequently present to eye clinics with ocular complications and side effects following these treatments, their severity ranging from ocular irritation from dry eyes to visual loss from vascular occlusion. A careful, thorough history is essential, as many patients may not associate aesthetic procedures with ocular complications, and some may be embarrassed to disclose this information. All ophthalmologists should understand the potential ocular sequelae of these treatments and be able to initiate treatment in sight-threatening cases. Wesummarises the current literature on ophthalmic complications of the most common periocular aesthetic treatments.

CLEAR - Anatomy and physiology of the anterior eye

A key element of contact lens practice involves clinical evaluation of anterior eye health, including the cornea and limbus, conjunctiva and sclera, eyelids and eyelashes, lacrimal system and tear film. This report reviews the fundamental anatomy and physiology of these structures, including the vascular supply, venous drainage, lymphatic drainage, sensory innervation, physiology and function. This is the foundation for considering the potential interactions with, and effects of, contact lens wear on the anterior eye. This information is not consistently published as academic research and this report provides a synthesis from all available sources. With respect to terminology, the report aims to promote the consistent use of nomenclature in the field, and generally adopts anatomical terms recommended by the Federative Committee for Anatomical Terminology. Techniques for the examination of the ocular surface are also discussed.

Botulinum Toxin A Injection for the Treatment of Intractable Dry Eye Disease

Background and Objectives: To evaluate the clinical efficacy of periocular botulinum toxin A (BTA) injection in patients with intractable dry eye disease (DED). Materials and Methods: Medical records of patients with intractable DED who underwent periocular BTA injection from December 2019 to March 2020 were reviewed retrospectively. Patients were injected with 2.5 units of BTA in the medial part of the lower eyelids. The clinical data collected included age, sex, ocular surface disease index (OSDI) score, tear film break up time (TBUT), Schirmer test results, tear osmolarity (I-PEN), and tear meniscus height (TMH) measured by anterior segment optical coherence tomography. All subjective and objective data were collected before treatment and at 1 month after treatment. Results: Twenty-eight consecutive patients were eligible for chart review and analysis. Significant improvements in OSDI, tear osmolarity, and TMH were observed at 1 month after periorbital BTA injection. At the baseline and 1-month follow-up examinations, OSDI scores were 62.22 ± 21.30 and 47.98 ± 17.23, respectively (p < 0.001). TMH increased significantly after treatment (82.25 ± 40.50 at baseline vs. 138.02 ± 66.62 1-month after treatment; p < 0.001). Tear osmolarity using I-PEN showed a significant decrease after treatment (320.82 ± 24.66 at baseline vs. 302.75 ± 22.33 at 1 month after treatment; p < 0.001). No significant differences were found in TBUT or Schirmer test results before and after BTA injection. Conclusions: BTA injection into the medial part of the eyelid improves dry eye symptoms, the amount of tear retention, and tear osmolarity. Based on the objective parameters of the tear condition, this study supports the idea of BTA use as a potential treatment option for patients with intractable DED.

Eye Conditions in Women

Changes in vision can have significant impact on health and quality of life. Differences between women and men have been identified in the incidence of several eye conditions. Some of these differences are a result of the greater longevity of women. However, the eye, like other organs, is susceptible to the impacts of inflammation and sex steroids. Conditions, such as thyroid eye disease, optic neuritis, and dry eye disease are related to autoimmune or inflammatory conditions and are, thus, more common among women. Idiopathic intracranial hypertension occurs disproportionately in women of childbearing age; the etiology of this condition appears to be related to both inflammatory and sex hormone fluctuations.

Characteristics of tear abnormalities associated with benign essential blepharospasm and amelioration by means of botulinum toxin type A treatment

PURPOSE

To investigate the characteristics of tear abnormalities with benign essential blepharospasm (BEB) and the effect of botulinum toxin type A (BTX-A) treatment.

STUDY DESIGN

Prospective and clinical study.

METHODS

Forty eyes of 40 patients (12 men and 28 women, ages 63.5 ±12.9) with BEB and tear abnormalities were enrolled.

RESULTS

The average scores for subjective symptoms as evaluated by the visual analog scale (VAS) were 46.3 and Dry Eye-Related Quality-of-Life Score (DEQS) were 63.7. The fluorescein breakup time (FBUT) was 2.7 ± 1.6 sec. Among fluorescein breakup patterns (FBUPs), dimple break, with the corresponding mechanism of decreased wettability was the most frequent, observed in 29 eyes (73%). The NEI score was 0.4 ± 0.7 and the van Bijesterveld score was 0.6 ± 0.8; the Schirmer 1 test value was 13.1 ± 9.4 mm. Eighteen patients received BTX-A treatment, and significant improvement was found in severity of subjective symptoms both on VAS and DEQS as well as for FBUT. The main FBUPs changed from dimple break to random break.

CONCLUSION

Tear abnormalities seen in BEB correspond to short BUT-type dry eye (DE), subclassified into decreased wettability DE in view of FBUPs.

Dry Eye Disease: Consideration for Women's Health

Dry eye disease (DED) is a multifactorial disorder of the ocular surface and tear homeostasis that can result in discomfort, pain, and visual disturbance. Untreated, DED can become chronic, progressive, and significantly affect an individual's quality of life. Women are disproportionately affected by DED, are diagnosed at a younger age, and experience more severe symptoms compared with men. DED is associated with a wide range of comorbid conditions; there is a strong association between DED and autoimmune disorders, especially those that affect women at many times the rate of men. Treatment response questionnaires indicate women respond better to a wellness model of treatment for DED than men. Furthermore, women's health care-seeking behaviors provide opportunities for general practitioners, specialists, and women's health centers to help identify women with DED or at risk for DED for referral to an eye care specialist. This review of the prevalence of DED in women, and gender and sex-specific aspects of DED, highlight a significant opportunity for action. Earlier diagnosis and treatment of this common but burdensome condition could significantly improve a woman's quality of life.

A Review of Periocular Botulinum Neurotoxin on the Tear Film Homeostasis and the Ocular Surface Change

Clinical usage of botulinum neurotoxin (BoNT) in ophthalmology has dramatically increased since the 1980s and has become one of the most widely used agents for treating facial movement disorders, autonomic dysfunction and aesthetic wrinkles. Despite its high efficacy, there are some complications with periocular BoNT injections due to its chemodenervation effect. Among these, there is still controversy over the BoNT effect on tear film homeostasis and the ocular surface. A periocular BoNT injection could dry the eye by reducing tear production of the lacrimal gland and increase tear evaporation due to potential eyelid malposition and abnormal blinks. On the contrary, the injection of BoNT in the medial eyelids could treat dry eye disease by impairing lacrimal drainage. Regarding the ocular surface change, corneal astigmatism and high-order aberrations may decrease due to less eyelid tension. In conclusion, the entire awareness of the effect of BoNT and the patients’ ocular condition is crucial for successful and safe results.

Botulinum toxin injection and tear production

PURPOSE OF REVIEW

In 1980, botulinum toxin type A (BTX-A) was introduced for the treatment of strabismus and benign essential blepharospasm. Since then, a number of additional indications have been introduced, which continue to expand, providing less invasive solutions in managing different ophthalmic conditions.

RECENT FINDINGS

Successful trials of BTX-A injection into the lacrimal gland have been reported for the treatment of epiphora caused by primary lacrimal gland hyperlacrimation, functional tearing, gustatory tearing, and lacrimal outflow obstruction. This is achieved through blockage of the cholinergic receptors by BTX-A at the glandular level. Interestingly, BTX-A has also been found to be useful in treating patients with dry eyes by compromising the tear drainage from the eye through injection of BTX-A in the medial part of the lower eyelid. BTX-A may help provide effective relief for patients who have two different ophthalmic comorbidities such as benign essential blepharospasm and dry eye.

SUMMARY

Better understanding of the mechanism of BTX-A action in the treatment of the growing applications in ophthalmology helps provide relatively noninvasive solutions for patients. Full awareness of possible side effects of BTX-A and the optimal way to manage them is vital for the success of this treatment option.

Application of botulinum toxin in Horner's muscle for the treatment of dry eye

OBJECTIVE/METHODS

The aim of this study is to describe the use of botulinum toxin to increase tear retention in patients with dry eye, using the description of 2 cases.

RESULTS

Patients with moderate to severe dry eye that were given an injection of type A botulinum toxin in the Horner's muscle. The results at one month and 3 months are reported. An assessment was made of the subjective perception of the patient as regards any improvement, as well as taking into account, the Ocular Surface Disease Index, superficial punctate keratitis, and the time of the tear rupture and tear meniscus. A significant improvement was observed in the subjective perception of the patient, the Ocular Surface Disease Index, superficial punctate keratitis, and the time of the tear rupture and tear meniscus at one month after treatment, and the good results still being maintained at the third month. There were no adverse events.

DISCUSSION

The use of type A botulinum toxin can be considered as an alternative to increase tear retention in moderate to severe dry eye, with a good response during the first month, with an acceptable response still being maintained at the third month. Given the temporary effect of the drug, further treatments would be required.

Increase lipid tear thickness after botulinum neurotoxin A injection in patients with blepharospasm and hemifacial spasm

The aim of this study was to investigate changes in the tear film lipid layer thickness (LLT) and aqueous tear production after botulinum neurotoxin A (BoNT) injection in patients with benign essential blepharospasm (BEB) and hemifacial spasm (HFS). Eleven and six patients with BEB and HFS, respectively, who received BoNT injection were consecutively enrolled in this prospective study. The blepharospasm disability index (BSDI), blink pattern, dry eye symptoms, Schirmer test 1 findings, LLT, eyelid performance, and corneal integrity were evaluated before and after treatment. Both BEB and HSF patients experienced remarkable relief from spasms and ocular discomfort after BoNT injection. LLT, the partial blink rate, the snap-back time, the lid distraction distance, and lateral canthal laxity were significantly increased at 1 month after treatment. There were no significant changes in Schirmer test 1 findings and meibomian gland dropout. Our findings suggest that LLT, a decisive factor for tear film stability, significantly increases at 1 month after BoNT injection for BEB and HFS. A decrease in BSDI and an increase in the snap-back time may contribute to the increase in LLT; this mechanism is probably responsible for the relief from dryness after BoNT injection in patients with facial movement disorders.

TFOS DEWS II iatrogenic report

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.

Paralysis of the orbicularis muscle of the eye using botulinum toxin type A in the treatment for dry eye

PURPOSE

To evaluate the efficacy of botulinum toxin type A injection to cause orbicularis eyelid muscle paralysis to improve dry eye signs and symptoms.

METHODS

A prospective, randomized, comparative eye-to-eye and interventional study was performed. Patients with dry eye symptoms and positive fluorescein corneal staining were included. Randomly one eyelid received a subcutaneous injection of botulinum toxin in the medial orbicularis muscle portion of the lower eyelid, and the other eye received placebo. The subjective evaluation was achieved with a questionnaire assessing symptoms, quality of vision and ocular comfort level. The objective evaluation included the measurement of the tear film break-up time (TBUT), Schirmer's test and corneal and conjunctival staining.

RESULTS

Twenty patients were included with a mean age of 59.5 years. Two weeks after the botulinum toxin injection, all patients showed a decrease in the horizontal movement of the lower eyelid when blinking. The eyes in the active treatment group showed better scores compared with the sham group in four symptoms 4 weeks after the treatment. The TBUT was higher at 1 and 3 months in the active treatment group. The corneal and conjunctival staining were significantly lower in the active treatment group at 1 and 3 months, and the Schirmer's test showed better measurements in the same group at 2 weeks, 1 month and 3 months. There were no adverse events reported.

CONCLUSIONS

The injection of botulinum toxin A in the medial part of the lower eyelid is an effective and safe procedure that temporally improves some of the signs and symptoms of patients with dry eye.

Comparison Between Botulinum Toxin A Injection and Lacrimal Punctal Plugs for the Control of Post-LASIK Dry Eye Manifestations: A Prospective Study

Introduction

Laser in situ keratomelieusis (LASIK) is one of the commonest refractive procedures performed nowadays. The dry eye problem is nearly universal in all patients after LASIK and it can be so annoying that the post-operative patient satisfaction is sometimes precluded. Conventional treatment includes the use of artificial tears. Alternative methods such as punctal plugs and botulinum toxin injection can be used for the management of post-LASIK dry eye. The aim of this study is to compare botulinum toxin injection in the orbicularis muscle to lacrimal punctal plugs for the control of post-LASIK dry eye manifestations.

Methods

This is a prospective study that included 60 patients who had LASIK eye surgery for correction of refractive errors. Patients were randomly assigned to one of three methods of dry eye management; the first method was conventional medical treatment with preservative-free tear substitutes only (group A: 20 patients = 40 eyes); the second method was intraoperative injection of botulinum toxin A (BTA) in the orbicularis muscle below the lower punctum of both eyes (group B: 20 patients = 40 eyes) and the third method was intraoperative insertion of temporary extended duration silicone punctal plugs in the lower punctum of both eyes (group C: 20 patients = 40 eyes).

Results

In the first follow-up visit after 2 weeks, the two test groups (B, C) showed a statistically significant increase in both tear film break up time (TBUT) and Schirmer test score with a decrease in the OSDI score and daily frequency of lubricants used in comparison to the control group A. These differences were maintained in the next follow-up visit but they became statistically insignificant at the 3rd and 6th post-operative months. Complications were encountered more in the punctal plug patients (60%) than in BTA patients (25%) and this difference was statistically significant.

Conclusion

The use of BTA injection to control dry eye symptoms by inducing temporary punctal ectropion is an effective method to improve patient satisfaction after LASIK eye surgery. It has higher level of patient satisfaction and fewer complications in comparison to punctal plugs or topical standard dry eye treatment.

Corneal and Tear Film Changes After Botulinum Toxin-A in Blepharospasm or Hemifacial Spasm

PURPOSE

To investigate changes in corneal parameters and the tear film after botulinum toxin-A (BTX-A) injection in patients with blepharospasm or hemifacial spasm.

METHODS

Twelve patients with benign essential blepharospasm and 30 with hemifacial spasm treated with BTX-A were included in this study. Disease severity was evaluated using the Jankovic scale. Corneal parameters were measured by the Pentacam. The Schirmer test score, tear breakup time, corneal fluorescein staining value, and Ocular Surface Disease Index score were also evaluated.

RESULTS

The BTX-A treatment relieved spasms in all of the patients. There was a statistically significant difference in disease severity between pretreatment and the third week (2.7 ± 0.8 and 1.3 ± 0.6, respectively; P < 0.001), but there was no statistically significant difference between pretreatment and the third month (2.7 ± 0.8 and 2.7 ± 0.8, respectively; P = 0.8). The tear breakup time was found to be significantly higher at both 3 weeks and 3 months after injection (6.6 ± 4.0 at pretreatment, 8.1 ± 3.9 at the third week, and 7.8 ± 4.2 at the third month; P = 0.04 and P = 0.02, respectively). The Schirmer test score, corneal fluorescein staining values, and Ocular Surface Disease Index score were lower 3 weeks after injection, but these values increased again by 3 months after injection. Corneal astigmatism decreased significantly at 3 weeks and at 3 months after injection [1.4 ± 1.2 diopters (D) at pretreatment, 1.2 ± 0.8 D at the third week, and 1.1 ± 0.8 D at the third month, respectively; P = 0.02, for both], but other corneal parameters did not change.

CONCLUSIONS

BTX-A injection therapy was affected the tear film in patients with blepharospasm or hemifacial spasm. However, there were no changes in corneal parameters, except corneal astigmatism, in these patients after treatment.

Comparison of Two Botulinum Neurotoxin A Injection Patterns with or without the Medial Lower Eyelid in the Treatment of Blepharospasm

The aim of this study was to evaluate the efficacy of two botulinum toxin A (BoNT-A) injection patterns with or without the medial lower eyelid (MLE) in treating benign essential blepharospasm (BEB) and influencing lacrimal drainage. Two different injection patterns of BoNT-A were randomly applied to 98 eyes of 49 BEB patients: MLE Group received a full injection pattern of 5 sites and non-MLE Group received a MLE waived injection pattern of 4 sites. Tear breakup time (BUT), Schirmer I test, lagophthalmos height, and lower lid tear meniscus height (TMH) were measured and Jankovic Rating Scale (JRS) was surveyed before injection and at 1 week, 1 month, and 3 months after injection. The symptom of BEB was relieved in both groups as suggested by JRS scores at all time points after injection, and MLE Group came up with a better JRS score at 3 months. The increases of Schirmer I test value and TMH in MLE Group were higher than those in non-MLE Group at 1 week after injection. This study shows that the MLE-involved full injection pattern is a better choice for patients with BEB. It has longer-lasting effects in relieving BEB symptoms and better efficacy in reducing lacrimal drainage. Clinical Trials registration number is NCT02327728.

Botulinum neurotoxin type A versus punctal plug insertion in the management of dry eye disease

Purpose:

To compare the efficacies of punctal plug insertion and Botulinum toxin injection in dry eye disease not responding to topical medications.

Materials and Methods:

A non-controlled randomized clinical trial of two parallel groups of 60 dry eye patients seen in the clinic not responding to topical medications were divided into two groups. One group received punctal plugs and the other group received Botulinum toxin injections to prevent lacrimal tear drainage.

Results:

Of a total of 36 patients with a mean age of 44.5 years who received punctal plugs, 50% of them experienced improvements in the clinical manifestations of their disease. 12/36 (33.3%) developed plug extrusion, and 6/36 (16.7%) patients developed conjunctival erosions with irritation that necessitated plug removal within one week of insertion. A total of 24 patients with a mean age of 47.5 years received injections of Botulinum toxin. Of these, 83.3% had improvement in all of the clinical manifestations of dry eye. 4/24 (16.7%) had no improvement in the degrees to which they experienced foreign body sensations, 33.3% reported shampoo entering the eye while showering. All of the patients who received Botulinum toxin injections were satisfied with the results of their treatment, whereas only 72.3% of the patients who received punctal plugs were satisfied with their results.

Conclusion:

Botulinum neurotoxin A injections can be a very good alternative to punctal plugs in improving the clinical manifestations of dry eye disease They are associated with the development of fewer and milder complications and with higher levels of patient satisfaction.

Ocular surface alterations in blepharospasm patients treated with botulinum toxin A injection

PURPOSE

To evaluate ocular surface changes secondary to periocular botulinum toxin A injection in patients with essential blepharospasm.

METHODS

Thirteen eyes of 13 patients with essential blepharospasm who underwent periocular botulinum toxin A injection were included in this prospective study. Patients were evaluated prior to and at 2-week and 1-, 3-, and 6-month time points following injections. Ocular surface tests were carried out in the order of tear break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and ocular surface disease index (OSDI) questionnaire for all patients. The Friedman test with Conover post hoc method was used for statistical comparisons of values at different time points.

RESULTS

The TBUT was found to be increased at 1 month after the injection (8.5 ± 2.1; p = 0.018) and decreased below baseline levels (6.4 ± 2.1) at the 6-month visit (5.7 ± 2.0; p = 0.018). None of the Schirmer test values at follow-up visits were significantly different as compared to baseline levels (11.3 ± 5.5), although the 2-week measurement (14.3 ± 5.6) was significantly higher as compared to that at the 6-month follow-up visit (9.6 ± 4.9; p = 0.034). There was also a significant decrease in LG staining scores at 2-week (0.6 ± 0.4; p = 0.012) and 1-month (0.6 ± 0.4; p = 0.012) time points compared to the baseline levels (1.1 ± 0.6). The OSDI scores improved at 2-week (5.4 ± 6.8; p<0.001), 1-month (3.2 ± 5.1; p<0.001), 3-month (2.5 ± 4.4; p<0.001), and 6-month (5.5 ± 5.4; p<0.001) time points as compared to baseline levels (11.6 ± 8.5).

CONCLUSIONS

Botulinum toxin A injection appears to have a positive but temporary effect on ocular surface parameters in patients with blepharospasm.

Tear production and drainage after botulinum toxin A injection in patients with essential blepharospasm

PURPOSE

To evaluate the clinical manifestations of tear production, distribution and drainage in the essential blepharospasm patients, and to analyse the changes after botulinum toxin A injection in these patients.

METHODS

This prospective study was performed in 23 patients with essential blepharospasm treated with Botulinum neurotoxin A (BoNT-A; Dysport, Ipsen Biopharm, UK) from November 2010 to February 2011. Ocular examinations, including frequency and severity of blepharospasm, tear break up time (BUT), Schirmer's test, lower lid tear meniscus height (TMH) measured by optical coherence tomography (OCT, rtvue software version 3.5; Optovue Inc., Fremont, CA, USA), and dacryoscintigraphy using 99m technetium pertechnetate, were performed before and 2 weeks after BoNT-A injection. We asked all patients about changes in the dry eye symptom score, before and after treatment. Results were analysed with independent t-test using spss software version 12.0 for Windows XP, (SPSS Inc., Chicago, IL, USA).

RESULTS

Botulinum neurotoxin A treatment relieved blepharospasm in all patients. Mean injection dose was 38 ± 5.6 units. After injection, mean tear BUT was significantly increased from 4.7 ± 4.9 to 6.6 ± 1.6 seconds (p = 0.001) Lower TMH increased in all three points and most notably at the lateral point (p = 0.05). On dacryoscintigraphy, tear drainage velocity was not affected by BoNT-A treatment. But Tc-99m 50% clearance time in interpalpebral fissure significantly increased from 1564 to 2220 seconds on the time activity curve (p = 0.027). Subjective dry eye symptoms also improved in 16 patients (70%) after injection.

CONCLUSION

Tear film stability and TMH increased, but tear drainage velocity was not affected by BoNT-A treatment. Overall Tc-99m 50% clearance time in interpalpebral fissure significantly increased, and tear storage from mild lateral lower eyelid laxity increased after BoNT-A injection. Botulinum neurotoxin A injection was also effective for combined dry eye symptom in the essential blepharospasm patients.

Botulinum toxin injections for blepharospasm prior to ocular surgeries

PURPOSE

The aim of this study was to show the efficiency of preoperative botulinum toxin A (Botox A) in patients with benign essential blepharospasm who were to undergo ocular surgery with local anesthesia.

MATERIALS AND METHODS

Twenty-eight benign essential blepharospasm patients who were administered unilateral Botox A prior to ocular surgery between January 2004 and May 2011 were included in this study. Eleven cases had pterygiums, ten had cataracts, and four had glaucomas, while the remaining three had aphakia. All cases' severity of spasm (stage 0-4) and eyelid closing forces (stage 1-4) were evaluated according to the Jankovic scale prior to the injection, at 3 days, 14 days, 1 month, and 3 months after Botox A injection.

RESULTS

Of the patients enrolled in the study, 16 were female and 12 were male, with an average age of 55.52 ± 1.53 years (52-65). Average onset of the Botox injection's effect was 2.8 ± 0.9 (2-5) days. Its effect lingered for about 11.5 ± 3.6 (8-22) weeks. The severity of spasm and eyelid closing forces of all the patients enrolled were compared prior to the injection at 3 and 14 days and the first and third months after the injection. There were statistically significant differences between prior to the injection and 3 days (P = 0.001), 14 days (P < 0.001) and 1 month after the injection (P < 0.001). There was no statistically significant difference between prior to the injection and 3 months after the injection (P = 0.513). Fourteen days following the injection, the surgeries were successfully performed.

CONCLUSION

Botox A administered prior to ocular surgery will control both blepharospasm and lower the risks that can be encountered before and during surgery, thus increasing the comfort of the patient and the surgeon.

An overview on dry eye treatment: approaches for cyclosporin a delivery

Dry eye syndrome (DES, Keratoconjunctivitis sicca) is a common disorder of the tear film caused by decreased tear production or increased evaporation. Changes in tear composition also promote inflammation on the ocular surface by various mechanisms. Artificial tear drops, tear retention treatment, stimulation of tear secretion, or anti-inflammatory drugs may be used for dry eye treatment according to the severity of the disease. For untreated patients, the risk of ocular infection increases at considerable level and clinical course of the disease may proceed up to infection, corneal ulcer, and blindness. Artificial tears and/or punctual occlusions are used for tear replacement or preservation. New treatment approaches are designed to modify the underlying disease process. For the treatment of severe dry eye disease, cyclosporin A (CsA), the first one of the new generation immunomodulatory drugs, which has an anti-inflammatory effect, is frequently used. CsA has immunosuppressive effects following systemic application. Following local administration of CsA, it is expected to obtain effective drug concentration at the target area and to avoid the various side effects associated with systemic delivery. Microspheres, implants, and liposomes have been developed for administration of CsA subconjunctivally in order to enhance its efficiency.

Uses of Botulinum Toxin a in Ophthalmology

Introduction:

Botox® (serotype A) is currently available and used to treat various ophthalmological conditions. The aim of our study was to review the current indications, side-effects and updates on the clinical use of botulinum toxin- A (Btx-A) in the field of ophthalmology.

Methods:

A literature search using the keywords “Botulinum Toxin”, “Botulinum Toxin A”, “Botox” and “Ophthalmology” was performed using Pubmed. Articles describing the use of botulinum toxin A were selected and reviewed.

Results:

The uses of Btx-A in ophthalmology can be broadly classified into four categories: eyelid, strabismus, cosmetic and others. In the eyelid, it can be used to treat blepharospasm, hemifacial spasm, apraxia of lid opening or induce ptosis in lid retraction and exposure keratopathy. In strabismus management, it can be injected into overacting muscles to realign the eyes. For cosmesis, it can be used to relax facial muscles to reduce wrinkles while other indications include treatment of chronic dry eye, lacrimal hypersecretion and pain relief in acute angle closure attack. Complications of the injection include local effects like ecchymosis, pain or infection and spillover effects like ptosis, diplopia, lagophthalmos, mid facial weakness and dry eyes.

Conclusion:

The clinical application of botulinum toxin A in ophthalmology is extensive. When considering its application in clinical practice, one should be mindful of the indications, risks and benefits of the procedure. When properly delivered, its potential as an efficacious, minimally-invasive treatment modality can be maximised in patient management.

Noncosmetic periocular therapeutic applications of botulinum toxin

Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.

Botulinum Toxin in Ophthalmology

Since its introduction into clinical medicine in 1980, botulinum toxin has become a major therapeutic drug with applications valuable to many medical sub-specialties. Its use was spearheaded in ophthalmology where its potential applications have expanded to cover a broad range of visually related disorders. These include dystonic movement disorders, strabismus, nystagmus, headache syndromes such as migraine, lacrimal hypersecretion syndromes, eyelid retraction, spastic entropion, compressive optic neuropathy, and, more recently, periorbital aesthetic uses. Botulinum toxin is a potent neurotoxin that blocks the release of acetylcholine at the neuromuscular junction of cholinergic nerves. When used appropriately it will weaken the force of muscular contraction, or inhibit glandular secretion. Recovery occurs over 3 to 4 months from nerve terminal sprouting and regeneration of inactivated proteins necessary for degranualtion of acetylcholine vesicles. Complications are related to chemodenervation of adjacent muscle groups, injection technique, and immunological mechanisms.

Effect of Botulinum Toxin Type A on Tear Production After Treatment of Lateral Canthal Rhytids

PURPOSE

To evaluate the incidence of temporary dry eye and the effects on lacrimal gland tear production after treatment of lateral canthal rhytids with botulinum toxin type A injections.

METHODS

Twenty-six crow's feet areas were injected with botulinum toxin type A in 13 women with an age range of 31 to 58 years. A total of 10 units of botulinum toxin was injected per side, with two separate injections. Schirmer 1 testing was performed before and at 1 week, 1 month, and 4 months after the injections in all patients. The test was repeated at 6 months and 9 months for the patients whose Schirmer test results were not back to baseline at the 4-month follow-up. Statistical significance was evaluated with paired t test analysis.

RESULTS

Overall, no statistical difference was found in Schirmer test results from baseline at 1 week (p = 0.23), 1 month (p = 0.32), or 4 months (p = 0.30) after injection. Five eyes of three patients had a significant decrease in Schirmer test results from baseline at 1 week and 1 month after injection. Three eyes of 2 patients had a significant decrease in Schirmer test results at 4 months after injection. Only one patient reported dry-eye symptoms at the 4-month follow-up. Schirmer test results of two eyes of one patient remained significantly lower than baseline at 6 months follow-up, which returned to the normal range at 9 months.

CONCLUSIONS

Botulinum toxin for lateral canthal rhytids usually does not suppress tear production. However, decreased tear production after botulinum toxin injection for crow's feet is a possible complication and patients should be advised of the small but definite risk of a temporary dry eye.

Acquired nasolacrimal duct obstruction

Acquired nasolacrimal duct obstruction is a common problem. Although tearing is the usual complaint, the clinical presentation can range from a patient having no symptoms to one with a life-threatening infection. Despite many studies providing useful clues, the exact pathophysiology of the obstructive process is incompletely understood. The clinician must be able to accurately make the diagnosis, which is often a clinical one, because many treatments with excellent success are available.

Managing adverse events associated with botulinum toxin type A: a focus on cosmetic procedures

Botulinum toxin A (BTXA) has become a widely used drug in cosmetic dermatology, not only to treat focal hyperhidrosis but also hyperkinetic facial lines, platysma bands, décolleté bands, and other skin features. The spectrum of possible adverse effects of BTXA is broad but fortunately those that have been observed with cosmetic use of this product are generally mild and transient. The major tools for preventing adverse effects from BTXA are knowledge and skill. Use of correct injection techniques is mandatory since most unwanted effects are caused by incorrect technique. Knowledge of the target structures, e.g. the facial and extrafacial muscles, allows physicians to select the optimal dose, time and technique. The most common adverse effects are pain and hematoma. In the periocular region, lid and brow ptosis are important adverse effects. Adverse effects such as pain, hematoma, ecchymosis, and bruising may also occur in the upper and lower face and at extrafacial sites. Other possible adverse effects seen in other indications that the user of BTXA in cosmetic dermatology should be wary of include induction headaches and possible interaction with concomitant medications. Induction of neutralizing antibodies due to cosmetic BTXA treatment has not been observed. This article also outlines recommendations regarding use of BTXA. Of these, the most important for avoiding most unwanted adverse effects are the proper techniques of dilution, storage, and injection, as well as the careful exclusion of patients with any contraindications. Pain, hematoma, ecchymosis, and bruising can be prevented by cooling the skin before and after BTXA injection. Upper lid ptosis may be partly corrected using apraclonidine or phenylephrine eyedrops. If simple rules relating to the indications for and application of BTXA are followed, this is a safe and effective drug in cosmetic dermatology.

Changes in the tear film and ocular surface from dry eye syndrome

Dry eye syndrome (DES) refers to a spectrum of ocular surface diseases with diverse and frequently multiple aetiologies. The common feature of the various manifestations of DES is an abnormal tear film. Tear film abnormalities associated with DES are tear deficiency, owing to insufficient supply or excessive loss, and anomalous tear composition. These categorizations are artificial, as in reality both often coexist. DES disrupts the homeostasis of the tear film with its adjacent structures, and adversely affects its ability to perform essential functions such as supporting the ocular surface epithelium and preventing microbial invasion. In addition, whatever the initial trigger, moderate and severe DES is characterized by ocular surface inflammation, which in turn becomes the cause and consequence of cell damage, creating a self-perpetuating cycle of deterioration. Progress has been made in our understanding of the aetiology and pathogenesis of DES, and these advances have encouraged a proliferation of therapeutic options. This article aims to amalgamate prevailing ideas of DES development, and to assist in that, relevant aspects of the structure, function, and production of the tear film are reviewed. Additionally, a synopsis of therapeutic strategies for DES is presented, detailing treatments currently available, and those in development.

Determination of relative contribution of the superior and inferior canaliculi to the lacrimal drainage system in health using the drop test

PURPOSE

The aim of this study was to explore the use of the 'drop test' as a method of assessing maximal lacrimal outflow capacity, and to measure the relative contribution of the superior and inferior canaliculi to the drainage capacity in normal subjects.

METHOD

The drop test involves instilling measured aliquots of normal saline over 3-min periods to raise the tear lake medially. Both eyes were assessed; however, for the right lacrimal drainage system only, sequential insertion and then removal of silicone punctal plugs was performed. After each stage the maximal lacrimal drainage capacity was measured. no punctal plugs were placed in the puncta on the left side.

RESULTS

Complete data were collected from 20 subjects with a mean age of 35.6 years. The intraclass correlation coefficient for the five left eye readings was 0.98 (CI 0.96-0.99) and the limits of agreement of a single reading were -22.6 to +93.0 micro L/3 min. Without intervention, no statistically significant difference was found in the mean lacrimal outflow between the left and right eyes (P = 0.16). A statistically significant reduction in outflow resulted from punctal occlusion (P < 0.05). Presenting the proportion of lacrimal outflow as a percentage of the combined values of the superior and inferior canaliculi, 59.9% of outflow occurred through the inferior canaliculus.

CONCLUSION

The drop test was found to provide a simple and repeatable method of assessing lacrimal drainage in a minimally invasive manner in the clinical setting. In healthy volunteers in the supine position 60% of maximal lacrimal outflow capacity occurs through the inferior canaliculus.

New Insights into the Diagnosis and Treatment of Dry Eye

Over the past decade, numerous advances have been made in relation to dry eye diagnostic markers, technologies, and treatment options. The mainstay of treatment of dry eye is the use of artificial tear solutions and punctum plugs. A goal is the development of agents that provide symptomatic treatment and, at the same time, improve ocular surface keratinization. It is the authors' opinion that the functional visual acuity tester and the new tear stability analysis system will be widely used to improve diagnosis and evaluate treatment outcomes in KCS. Advances in treatment will utilize anti-inflammatory agents, immune suppressants such as Cyclosporin A and FK-506, growth hormones, androgens, topical mucins and ocular surface stimulating drugs, like INS365. Although aqueous-deficient dry eye is most commonly not associated with Sjogren syndrome (SS), aqueous-deficient dry eye is often most severe in patients with SS; thus, this article focuses mainly on SS-associated dry eye.

Noncosmetic uses of botulinum toxin

In conclusion, botulinum toxin usage over the past 2 to 3 decades has expanded exponentially. Almost every discipline in medicine has found some therapeutic use for this toxin. Botulinum toxin has been shown to be safe, effective, and relatively easy to administer with proper training.

Noncosmetic uses of botulinum toxin

Since the introduction of botulinum toxin (BTX) as a therapeutic tool in the 1970s, the number of uses for this substance has increased exponentially. BTX's mechanism of action involves degrading the SNARE proteins blockading the release of acetylcholine into the neuromuscular junction. In many body systems, decrease of contractility, strength, and tension of certain muscle groups result in improved clinical outcomes. Applications now include cosmetic, gastroenterologic, otolaryngologic, genitourinary, neurologic, and dermatologic uses. In fact, BTX can be considered as a potential treatment in any situation involving inappropriate or exaggerated muscle contraction. Currently, the FDA has approved BTX-A (Botox) for treating glabellar lines, blepharospasm, strabismus, hemifacial spasm, cervical dystonia, and spasticity. With the addition of cosmetic applications to the FDA's approval list, the use of BTX has increased dramatically.

Ocular surface changes in keratoconjunctivitis sicca with silicone punctum plug occlusion

PURPOSE

To evaluate histopathologic and clinical response to silicone plug insertion in dry eye patients.

METHODS

Punctal plugs were placed in 32 eyes of 18 dry eye patients with aqueous deficiency who were on maximum medical therapy and who had Schirmer testing with topical anesthetic measuring less than 5 mm. Pre-treatment and post-treatment (6 weeks and 1 year) evaluations included temporal and inferior quadrant impression cytology examinations, Schirmer-1, BUT, corneal fluorescein and rose-bengal staining patterns and questionnaire scores. The cytology samples were graded according to the method described by Nelson.

RESULTS

There was an improvement in subjective symptoms of patients 6 weeks after punctal occlusion. Corneal fluorescein and rose-bengal staining scores decreased from a mean of 5.33 +/- 1.74 to 1.37 +/- 1.48 and from 5.90 +/- 1.2 to 2.45 +/- 1.89 (p < 0.05) respectively. BUT values increased from 2.98 +/- 1.1 to 11.3 +/- 3.1 seconds (p < 0.05) at 6 weeks post-treatment. Increase in goblet cell density was observed after punctal occlusion at 6 weeks (p < 0.05) and at 1 year (p < 0.05) compared to the pre-treatment values. After occlusion, 3% of temporal specimens had Grade 0 squamous metaplasia, 63% had Grade 1, 34% had Grade 2; while 25% of inferior specimens had Grade 0, 56% had Grade 1, 19% had Grade 2 squamous metaplasia.

CONCLUSIONS

Punctum plug occlusion in keratoconjunctivitis sicca provides improvement of tear film stability, ocular surface staining scores, conjunctival squamous metaplasia grades and goblet cell density. Increased ocular surface exposure to essential tear components with punctal occlusion may be important for the genesis of these changes.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.

Lid restraint evokes two types of motor adaptation

Unilateral reduction in eyelid motility produced two modes of blink adaptation in humans. The first adaptive modification affected both eyelids. Stimulation of the supraorbital branch of the trigeminal nerve (SO) ipsilateral to the upper eyelid with reduced motility evoked bilateral, hyperexcitable reflex blinks, whereas contralateral SO stimulation elicited normally excitable blinks bilaterally. The probability of blink oscillations evoked by stimulation of the ipsilateral SO also increased with a reduction in lid motility. The increased probability of blink oscillations correlated with the enhanced trigeminal reflex blink excitability. Thus, the trigeminal complex ipsilateral to the restrained eyelid coordinated an increase in excitability and blink oscillations independent of the eyelid experiencing reduced motility. The second type of modification appeared only in the eyelid experiencing reduced motility. When tested immediately after removing lid restraint, blink amplitude increased in this eyelid relative to the normal eyelid regardless of the stimulated SO. A patient with seventh nerve palsy exhibited the same two patterns of blink adaptation. These results were consistent with two forms of adaptation, presumably because unilateral lid restraint produced two error signals. The corneal irritation caused by reduced blink amplitude generated abnormal corneal inputs. The difference between proprioceptive feedback from the blink and expected blink magnitude signaled an error in blink amplitude. The corneal irritation appeared to drive an adaptive process organized through the trigeminal complex, whereas the proprioceptive error signal drove an adaptive process involving just the motoneurons controlling the restrained eyelid.

The use of botulinum toxin in ophthalmology

As the diversity of clinical applications for the botulinum neurotoxin continues to grow, exciting developments are occurring in its use around the eye, where indeed its benefits were first recognized. These include use to treat strabismus, eyelid disorders and a number of other ocular conditions.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.

The treatment of dry eye

The most widely used therapy for dry eye disease is tear replacement by topical artificial tears. Punctal occlusion to prevent the drainage of natural or artificial tears is the most common non-pharmacological treatment. These and other traditional therapies for dry eye disease are only palliative, however, as they replace or conserve the tears without necessarily correcting the underlying disease process. As our understanding of the pathology of dry eye disease improves, new treatment strategies are being developed. Topical anti-inflammatory and immunomodulatory agents, such as cyclosporin A, are under investigation in the treatment of dry eye, as it is anticipated that they will correct the vicious cycle of inflammation and cell damage on the ocular surface and lacrimal glands.