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Botox Injection to the Lacrimal Gland for the Treatment of Epiphora

R. Jeffrey Hofmann

Botox injection to the lacrimal gland can be useful to control epiphora in patients with no drainage system. I have had a number of patients that lost their lacrimal sac following extirpation of a tumor. Some of them refused Jones tube surgery, while others were simply poor surgical candidates. Botox injection to the lacrimal gland is very effective at controlling their symptoms of epiphora, as it is with “crocodile tears” after a Bell’s palsy.

Using a 1/2 30-gauge needle on a tuberculin syringe, I advance the needle through the skin near the superotemporal orbital rim (Figure 109.1). I aim the needle directly posteriorly for the first 2 mm and then direct the needle superotemporally so that I am in the lacrimal gland fossa. In order to be as far away as possible from the rectus muscles or levator muscle (and avoid diplopia or ptosis), I actually touch bone with the needle tip within the lacrimal gland fossa (Figure 109.2). I then inject 0.1 cc (3.3 units) as I withdraw the needle just a millimeter (so that I am off the bones) (Figure 109.3). This usually gives significant relief from epiphora for 6–8 months.

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Chapter 109 Botox Injection to the Lacrimal Gland for the Treatment of Epiphora 333

Figure 109.1. The blue “L” marks the point of injection for the lacrimal gland.

Figure 109.2. After entering the skin, the nedle is advanced posteriorly and superotemporally within the lacrimal gland fossa.

110

Botox Therapy for Hyperhydrosis: How I Do It

Charles B. Slonim

Hyperhidrosis is the poor man’s detection method for determining where to inject botox:

1.Paint the area (e.g., axilla) with betadine solution (a betadine wipe will do)

2. Allow the betadine to dry

3.Apply a thin layer of cornstarch or fine talc powder over the betadine

4.Shine a handheld spotlight with a 100 W bulb directly on the area

5.The areas of hyperhidrosis will be stimulated and the moisture will cause the betadine to “bleed” through the white powder or cornstarch

6.Photograph the area for documentation

7.Apply a layer of a topical anesthetic (e.g., betacaine, EMLA, etc.)

8.Inject Botox into the dermis in a grid pattern in the targeted area with approximately 1 cm between injections

9.Use 2.5 units in 0.05 cc per injection site

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111

Other Uses of Botox

John R. Burroughs and Richard L. Anderson

We have had good results for hyperlacrimation by subconjunctivally injecting 1–3 units into the palpebral lobe of the lacrimal gland. This has been very helpful for patients suffering gustatory crocodile tearing from aberrant regeneration.

Severe lid retraction in active inflammatory dysthroid ophthalmopathy can be treated with a 2–10 units of Botox® given subconjunctivally, supratarsally to the upper eyelid elevator complex.

Low dose and precisely placed, Botox injections have also been helpful for the temporary management of mild to moderate blepharoptosis, with aesthetic augmentation of the vertical palpebral aperture and eyelid

ssure asymmetries.

Patients with lagophthalmos and eyelid retraction, with exposure keratopathy from facial palsy, may benefit from improved ocular surface coverage by inducing a blepharoptosis (Botox tarsorraphy). When conservative treatment has been inadequate or if the patient is a poor or unwilling surgical candidate, then a Botox-induced blepharoptosis can be achieved by injecting 5–10 units in the central upper eyelid.

Spastic entropion may respond to a few units given to the lower eyelid pretarsal orbicularis.

Botox can be a “miracle” treatment for migraine headache patients refractory to routine treatments and may require large doses in corrugators, temporalis, occipitalis, and frontalis muscles, so we generally dilute the Botox with 2.5 ml (4 units/0.1 ml) of preserved saline. Careful patient questioning and examination to precisely identify trigger areas is critical.

Common trigger areas are the glabella, forehead, temples, and occipital musculature.

Newer oculofacial applications include treatment of oral incontinence in facial paralysis patients. Facial and lip droop can make it difficult to drink and retain fluids and food in the oral cavity during consumption.

Small doses to the unaffected side can lessen the angle and asymmetry between the two sides of the oral commissure, which can lessen the incidence or severity of oral incontinence. Injections to the unaffected forehead and face in facial paralysis patients helps provide symmetry and may help stimulate reinnervation on the affected side. Postoperative

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112

Botox for Axillary Hyperhydrosis

R. Jeffrey Hofmann

I have treated a number of patients with axillary hyperhydrosis. I have tried the various methods and doses and have found that 100 units (50 units per side) is very effective for about 8 months. This is consistent with what I found with facial hyperhydrosis in Frey’s syndrome.

I use 4 cc of saline to reconstitute the Botox (2.5 units per 0.1 cc). I create a grid pattern in each armpit in the hair-bearing area. Each grid is approximately 4 cm × 5 cm (or sometimes 3 cm 7 cm, depending on the hair distribution pattern). This results in 20–21 different 1 cm 1 cm injection sites in each armpit. Each injection is 2.5 units (0.1 cc) and is injected intradermally. Inject intradermally rather than subdermally because the target (the sweat gland) is within the dermis. It is nice to see a blanched wheal at each of the injection sites. I find it easier to inect intradermally if I hold and “pinch up” the skin with my left thumb and

nger while injecting with my right hand.

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