Botulinum toxin in Ophthalmic Practice

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Botulinum toxin in Ophthalmic Practice

• Dr Sunayana Bhat
• Consultant
• Paediatric ophthalmology , Strabismus and Neuro
  ophthalmology
• Vasan eye care , Mangalore
• Ph 9611102754
• chanyn9_at_gmail.com

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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 150 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
50 100 u
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Eyelid diseases

• Retraction
• graves 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