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Botulinum toxin injection controls crocodile tears
By Cheryl Guttman
Fort Lauderdale — Intraglandular injection of botulinum toxin
type A (BTX-A, Botox) is a safe and very useful treatment for patients
with gustatory epiphora, commonly known as crocodile tears.
Angel Nava-Castañeda MD described using Botox in the treatment
of 16 patients with this condition at the annual meeting of the
Association for Research in Vision and Ophthalmology.
Each received an injection of 2.5 U/0.05 mL delivered directly into
the palpebral lobe of the affected lacrimal gland using an insulin
syringe.
The majority of patients improved rapidly and all achieved complete
responses within one month based on both objective and subjective
evaluations. The treatment effect was relatively durable, ranging
from 11 to 25 weeks (mean 18.3 weeks). It lasted more than five
months in five (30%) patients.
Dr Nava-Castañeda, a fellow in the Orbit and Oculoplastics
Service, Instituto de Oftalmologia Fundacion Conde de Valenciana,
Mexico City, reported that the treatment was safe and well tolerated.
Two patients developed ptosis which resolved spontaneously. No patients
complained of dry eye and there were no other adverse events in
the series.
“Tearing evoked by gustatory stimulation is not a common pathology,
although it is a frequent problem in patients with severe proximal
seventh nerve palsy and very troublesome for those individuals.
Findings from previous case reports and small case series indicate
a beneficial role of intraglandular BTX-A for decreasing this hyperlacrimation.
Our experience in a larger group of patients corroborates those
reports on its efficacy and safety and adds further information
about the duration of action, which appears to be longer than when
this agent is used in other ocular conditions like blepharospasm,”
Dr Nava-Castañeda explained.
The patients treated were a consecutive group presenting with a
minimum six-month history of gustatory epiphora secondary to seventh
nerve palsy. Researchers obtained informed consent from all patients
and completed full ophthalmological examinations to rule out other
causes for hyperlacrimation.
The investigators measured objective responses to Botox injection
with a modified Schirmer test, with anaesthesia performed during
chewing.
Patients also provided subjective ratings. Mean Schirmer values
fell from 11.7 at baseline to 8.5 at one week, at which time 11
(68%) patients reported improvement. At subsequent visits conducted
at one and three months, the mean Schirmer value was reduced even
further to 7.6 and 7.1, respectively.
Values began to show an increase at six months, when the mean value
was 7.7. Schirmer values remained relatively stable in the untreated
eye throughout the follow-up and were higher than in the treated
eye beginning at one week.
Retreatment in some patients
Eleven patients in the series have received repeat injections. Ten
patients were retreated four to five months after the initial injection.
The eleventh was retreated after three months. Those individuals
are now being followed to assess the durability of their response
“We are interested in seeing whether the benefit of a second
treatment is as long-lasting as the first. In the future, we might
consider a higher dose, perhaps 5 U, for a second injection if we
find the response is less persistent or in patients who have relatively
early recurrence of hyperlacrimation after initial treatment.
“However, in other indications, there has not been evidence
for a relationship between BTX-A dose and duration of effect,”
Dr Nava-Castañeda noted.
BOTOX is a product of Allergan. Dr Nava-Castañeda has no
financial interest in that company.
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