Indications for botulinum toxin treatment continue
Stefanie Petrou-Binder MD in Nürnberg
BOTULINUM toxin A is an effective treatment option for spastic entropion,
according to a study presented at the XVI Annual Meeting of German
Daniela Claessens MD injected botulinum toxin (Dysport, Ipsen/Botox,
Allergan) in ten eyes of ten patients with spastic entropion of
the lower lid to achieve eversion of the lower lid. Entropion surgery
in these patients was either contraindicated or the patients did
not consent to the operation. Patients' diagnoses ranged from spastic
entropion in eight patients, to one case of ocular pemphigoid, and
one case of trachoma.
In the three to ten days following the procedure, Dr. Claessens
reported that nine of the study patients with successfully everted
lower lids were symptom free. In one patient, she administered another
20 IU two weeks later following the development of trichiasis. She
further noted that one patient developed a small haematoma and four
of the patients experienced viral-like symptoms. The paralysis induced
by botulinum toxin A lasted for three to six months.
To prepare the injection solution, Dr. Claessens took 2.5 ml of
sterile sodium chloride and 500 IU of botulinum toxin and injected
them into the injection bottle, which produced a clear solution
of 20 IU per 0.1 ml. After disinfecting the skin, she allowed a
period of five minutes to elapse to avoid any denaturisation of
the protein components of the botulinum toxin by the alcohol.
Using a 20-gauge needle, Dr. Claessens injected a total of 60 IU
of botulinum toxin A at two different sites in the orbicular muscle
of the lateral lower lid in all ten patients. She was able to monitor
the dosage during the administration by implementing a 1.0 ml syringe
with a 0.01 ml scale.
She applied a simple ice pack to control pain immediately following
the injection and to counteract the diffusion of the toxin through
vasoconstriction. She then observed the patients for one hour following
the procedure to rule out the possibility of an allergic reaction
to the drug. She carefully monitored her patients for two weeks.
Dr. Claessens explained that the contraindications for this procedure
included disturbances of the motor endplate, hypersensitivity to
one of the components of the drug, simultaneous treatment with aminoglycoside
antibiotics, marked chronic respiratory complaints, deglutition
complaints, disturbances in coagulation, infection at injection
site, and pregnancy or nursing.
The possible reversible general side effects included haematoma,
temporary exaggerated muscle weakness at injection site, and the
involvement of other muscles through diffusion.
More specifically to the toxin itself, she noted that ectropion
and double vision could occur if the injection is given too far
medially, through diffusion to the inferior oblique muscle. These
potential side effects are reversible.
She stressed that the therapeutic employment of botulinum toxin
outside of the established indications requires a detailed discussion
and informed consent of the patient.
In a related presentation, Peter Roggenkaemper MD reviewed the manifold
uses of botulinum toxin that range from the clinical to the purely
"Aside from spastic entropion, other indications for botulinum
injection include the treatment of wrinkles (Crow's feet, glabellar
wrinkles), to attain protective ptosis in poorly healing corneal
ulcers, for stopping hypersecretion of the lacrimal glands, and
for treatment of blepharo- and hemifacial spasms," he said.
He reported that he had seen excellent results in alleviating lid
spasms in series of more than 2400 cases of blepharospasm, which
had effectively blinded many of his patients due to the severity
of the spasm. The effects of the treatments usually lasted three
to four months, with considerable variation in the effective dosage
and duration of action among patients.
He commented that patients could be treated over the long term with
little or no diminution of the effects. He cited examples of patients
who had been injected up to ninety times over a period of many years.
He explained that although the inhibition of the neurotransmitter
acetylcholine by botulinum is irreversible, new receptors begin
to sprout within the neuromuscular junction after a few weeks, which
allow the muscle to resume its function.
According to Dr Roggenkaemper, the worst complication involved with
Botox treatment is ptosis, which can be avoided by injecting at
a small distance from the levator muscle. Should this complication
occur, however, it will persist for several months until the action
of the toxin is overcome by new acetylcholine receptors.
In the 5%-10% of blepharospasm cases for which botulinum injection
is ineffective, Dr Roggenkaemper performs suspension surgery, which
is well tolerated by patients, he added.
Daniela Claessens MD
Fax: + 49 221 407 200
Peter Roggenkaemper MD
University Eye Clinic, Bonn, Germany