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

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 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 Frontalis Temporalis muscle on both sides
Mechanism
Relaxation of corrugator ?
Nociceptive activity
Frontalis
Temporalis muscle on both sides
Occipital muscle
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