Botulinum toxin in Ophthalmic Practice

1. Botulinum toxin in Ophthalmic Practice Dr Sunayana Bhat Consultant Paediatric ophthalmology , Strabismus and Neuro ophthalmology Vasan eye care , Mangalore Ph : 9611102754 chanyn9@gmail.com

2. Botulinum toxin injections are the fastest-growing cosmetic procedure all over the world • Neurotoxin : Bacterium “Clostridium botulinum” • 'botulus' sausage German physician who described the poisoning after the ingestion of sausage.

3. Mechanism of action • Activity and dosing • Clinically available forms • Uses • Complications

4. Mechanism of action • Heavy chain of 100 kDa • Light chain of 50 kDa 150 kDa core type A molecule

5. Mechanism of action ENDOCYTOSIS SUBSTRATE MODIFICATION

6. Mechanism of action • Differ in SNARE protein / cleavage site A,B,C,D,E,F PROCESS OF FUNCTIONAL RECOVERY Sprouting of nerve fibers from the terminal axons Extra junctional Ach receptors

7. Activity and Dosing • 1 unit : LD50 female swiss webster mice , intra peritoneal injection • 1 unit : 0.05 ng of toxin • Stored dry • Reconstitution with saline 5-10 u : 0.1 ml

8. Commercial Preparations

10. Benign Essential Blepharospasm • Functional blindness : Episodic Spasms • Effective in 75% • 2.5 u each site … • Subcutaneous • Sites :

11. Stabismus : Muscle Inj • Post paralytic ( prevent contractures ) • With transpositions : for horizontals • Dysthyroid orbitopathy • Surgical surprises ! • Infantile ET ??? Buying time

12. Nystagmus / Oscillopsia The "ideal" patient for retrobulbar Botox -restricted movement -oscillopsia, -willing to use only one eye. 

13. Chronic Dry Eyes Medial orbicularis muscle : inj failed lacrimal pump Subjective improvement of symptoms in 70% of cases

14. Post Peripheral Facial Nerve Synkinesis • Facial deformity • Drooling • Twitching / muscle spasms

15. Tics,Tremors and Myokymia • Spontaneous discharges • Known to resolve spontaneously 2.5 u

16. Elevated IOP due to Restrictive Myopathy Corneal Protective Ptosis Direct infiltration of levator muscle

17. Headache Syndromes 50 – 100 u

18. Eyelid diseases • Retraction grave’s disease • Spastic Entropion Pre tarsal orbicularis overides • Ocular sx • Irritation

19. Compressive Optic Neuropathy • Enlarged muscles : crowding • Reduced contraction • Reduced muscle bulk

20. Hyperhydrosis Lacrimal Hypersecretion syndromes • 1% population • Face , axilla , palms • Frey syndrome : gustatory sweating • Gustatory epiphora 2.5 U palpebral lobe of lacrimal gland 8 mm of schirmer value reduction

21. Aesthetic uses • Forehead furrows • Glabellar lines • Lateral rhytides ( crows feet ) • Brow lift • Perioral rhytides ( smokers lines ) • Mesolabial folds (marionette lines ) • Platysmal bands

23. ALL IS WELL………….

24. Complications • Ptosis - always transient • Induced deviations - usually transient • Diplopia - transient • Dilated pupil - rare • Reduced accommodation - rare • Scleral perforation* - rare - potentially serious • Lip droop - very bothersome; may be persistent

25. Future Trends • Antibody development …. • Complication : anti globulin within 4 hrs • Bioterrorism ……VACCINES ????.....

26. Thank u