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Botulinum toxin treatment

Botulinum toxin has been used safely since 1986 for the treatment of various ocular conditions and for cosmetic rejuvenation of the face.

In the field of ophthalmology, it is most commonly used for the treatment of involuntary spasm of the eyelid and facial muscles. These conditions are known as essential blepharospasm or hemifacial spasm. It is also used to reduce skin wrinkling particularly of the brow and upper face.

A small amount of toxin is injected into the skin. After a few days it starts to weaken the muscles beneath the skin. It is a safe procedure, but its effects are temporary and regular repeated injections are needed.

What is blepharospasm?

Blepharospasm is an involuntary movement of some of the facial muscles around the eye. It affects men and women usually between 50 and 70 years of age. It results in uncontrollable blinking and closure of the eyes and may cause a minor annoyance but may be severely disabling, preventing sufferers from carrying out their daily activities.

What causes blepharospasm?

It is not know what causes blepharospasm but it may be caused by a wiring abnormality in the basal ganglia, part of the brain responsible for controlling movement. The brain may send out inappropriate messages to the muscles causing them to contract at the wrong time. The symptoms of blepharospasm may be made worse by other irritating eye conditions such as lid inflammation.

What is hemifacial spasm?

Hemifacial spasm is an involuntary contracting of muscles on one side of the face. It is caused by an inappropriate stimulation of the facial muscles by the facial nerve. It may occur after a paralysis of the facial nerve (Bells Palsy) but may also be caused by pressure on the facial nerve by an abnormal blood vessel in the neck.

What treatments are available?

For blepharospasm and hemifacial spasm, the most likely treatment that you will be offered first is botulinum toxin treatment (see below). Medications are sometimes suggested but the results of treatment are disappointing.

If botulinum toxin treatment fails or is unacceptable to the patient, surgical measures may be taken. For blepharospasm, a lid operation may be performed to remove some skin and some of the muscle that is twitching. This helps in about 50% of patients and in those patients who are not helped by this alone, the efficacy of further botulinum injections may be enhanced. For hemifacial spasm, the pressure on the facial nerve may be reduced in an operation performed by a neurosurgeon. There are potential risks of surgery which will be discussed with you and which make this operation only suitable for certain patients.

What is botulinum toxin?

Botulinum toxin is the chemical produced by the bacteria Clostridium botulinum. It has a potent ability to paralyse muscles. The toxin will only paralyse muscles where it is injected and can not cause the deadly disease botulism because no active bacteria are present in the injection.

What happens during treatment?

You will have a very small amount of the drug injected under the skin, usually in three or four places around the eye. If some of the other facial muscles are affected, they too may be injected. The injections may sting a little and you may have a small amount of bruising at the injection site. The treatment usually starts working during the first week and will usually last for between two or three months after which a repeat injection may be offered. Occasionally, the effect wears off much sooner but in some patients, the effects may last for six months or so.

What are the side effects?

Very occasionally, patients may be allergic to the botulinum. The side effects are temporary and usually relate to the treatment working "too well". Occasionally the muscles around the eye are paralysed too much, causing the lower lid to turn out. Rarely, the eye may become red and sore due to reduced closure of the eye. If this happens contact the eye doctor immediately. The upper eyelid may droop and occasionally the patient experiences double vision because the toxin gets into one of the muscles around the eye. If you get any discomfort of the eye after botulinum toxin treatment, please contact the eye team for advice. The side effects usually subside after a few weeks.

Please note, it is inadvisable to undergo treatment with botulinum toxin if you are pregnant or are breastfeeding.

Will I need repeated injections?

It is most likely that you will require repeated injections for as long as you have symptoms, usually for many years. There is some evidence to suggest that the interval between injections can increase with time. Occasionally, the condition disappears for no apparent reason.

If you have any questions regarding this information, please ask your eye doctor.


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