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Botulinum toxin in Ophthalmic Practice
Dr Sunayana Bhat Consultant Paediatric ophthalmology , Strabismus and Neuro ophthalmology Vasan eye care , Mangalore Ph :
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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.
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Mechanism of action Activity and dosing Clinically available forms Uses Complications
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Mechanism of action Heavy chain of 100 kDa
Light chain of 50 kDa kDa core type A molecule
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Mechanism of action ENDOCYTOSIS SUBSTRATE MODIFICATION
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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
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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
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Commercial Preparations
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Benign Essential Blepharospasm
Functional blindness : Episodic Spasms Effective in 75% 2.5 u each site … Subcutaneous Sites :
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Stabismus : Muscle Inj Post paralytic ( prevent contractures )
With transpositions : for horizontals Dysthyroid orbitopathy Surgical surprises ! Infantile ET ??? Buying time
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Nystagmus / Oscillopsia
The "ideal" patient for retrobulbar Botox -restricted movement -oscillopsia, -willing to use only one eye.
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Chronic Dry Eyes Medial orbicularis muscle : inj failed lacrimal pump Subjective improvement of symptoms in 70% of cases
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Post Peripheral Facial Nerve Synkinesis
Facial deformity Drooling Twitching / muscle spasms
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Tics,Tremors and Myokymia
Spontaneous discharges Known to resolve spontaneously 2.5 u
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Elevated IOP due to Restrictive Myopathy
Corneal Protective Ptosis Direct infiltration of levator muscle
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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
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Eyelid diseases Retraction grave’s disease Spastic Entropion
Pre tarsal orbicularis overides Ocular sx Irritation
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Compressive Optic Neuropathy
Enlarged muscles : crowding Reduced contraction Reduced muscle bulk
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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
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Aesthetic uses Forehead furrows Glabellar lines
Lateral rhytides ( crows feet ) Brow lift Perioral rhytides ( smokers lines ) Mesolabial folds (marionette lines ) Platysmal bands
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ALL IS WELL………….
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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
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Future Trends Antibody development ….
Complication : anti globulin within 4 hrs Bioterrorism ……VACCINES ????.....
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Thank u
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