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Acute angle closure attack following periorbital botulinum toxin A injection for cosmesis

Poster Details

First Author: D.Wiwatwongwana THAILAND

Co Author(s):    A. Wiwatwongwana   W. Chaidaroon           

Abstract Details


To report a case of acute angle closure attack after cosmetic Botulinum toxin A injection around the orbit.


Chiang Mai University Hospital


case report


A 60-year-old woman who complained of right periorbital pain and blurry vision for 3 days was referred to the glaucoma clinic. She was previously diagnosed with bilateral primary open angle glaucoma, currently treated with Travoprost and Timoptol. Her intraocular pressures (IOP) were well-controlled ranging from 12-14 mmHg. Gonioscopy had not been performed. She had undergone periorbital Botulinum toxin A injection for crow's feet and frown lines between the eye brows 3 days prior to eye symptoms. Upon presentation her visual acuities were 20/200, OD and 20/20, OS. Slit lamp examination of the right eye revealed edematous cornea, shallow anterior chamber and IOP of 36 mmHg. The left eye had a mildly shallow anterior chamber with IOP of 14 mmHg. Gonioscopy revealed grade 0 by Shaffer classification in all quadrants in the right eye, grade 1 superior and inferior and grade 2 nasal and temporal in the left eye. She was immediately treated with oral acetazolamide 500 mg and topical 2%Pilocarpine. Bilateral laser iridotomies were performed with a neodymium-yttrium-aluminium-garnet laser. On the following day, the IOP reduced to 13mmHg, OU and visual acuity improved to 20/40, OD. At 3 month follow-up, her IOP was controlled at 14 mmHg, OU with Travoprost.


Botulinum toxin is a neurotoxin which inhibits the release of acetylcholine at peripheral cholinergic synapses. When injected periocularly, it could diffuse to the ciliary ganglion inhibiting the pupillary sphincter and causing pupil dilatation. Through this mechanism, acute angle closure attack could be induced, especially in predisposed patients with narrow anterior chamber angles. The first report of acute angle closure glaucoma associated with Botulinum toxin A injection for blepharospasm was reported by Corridan et al. Our patient was misdiagnosed and treated as open angle glaucoma, therefore laser peripheral iridotomy was not performed prior to referral. Hence she was at risk for acute angle closure attack induced by pupillary dilatation following Botulinum toxin A injection for cosmesis. Emergency laser peripheral iridotomy was performed to reverse the pupillary block. We recommend that gonioscopy should be performed prior to periorbital Botulinum toxin A injection. Though rarely occurs, physicians and patients should be aware of this potential side effect and patients should be warned of glaucoma symptoms. FINANCIAL INTEREST: NONE

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