Botulinum toxin injection for the treatment of epiphora in lacrimal outflow obstruction

Abstract

Purpose: To describe our experience with the use of botulinum toxin (BoNTA) for the symptomatic treatment of lacrimal outflow obstruction. Methods: We retrospectively reviewed the case notes of patients with epiphora due to lacrimal outflow obstruction who chose to have injections of botulinum toxin into the palpebral lobe of the lacrimal gland instead of surgery between 2009 and 2014. Epiphora was graded subjectively with Munk scores obtained before and after treatment as well as qualitative degree of improvement reported by the patients. Severity and duration of side effects were also noted. Results: Seventeen patients (22 eyes, mean age 70.3, 4 males and 13 females) were identified. A mean of 3.5 (range; 1-10) injections of BoNTA (Botox, Allergan; 1.25-7.5 units) were given per eye. The mean interval between injections was 3.9 months (range 3-6). The mean Munk score (3.4, range 2-4) improved significantly after treatment to 1.6 (range: 0-3, P = 0.0001 paired two-tailed t-test). Epiphora completely resolved in a fifth, improved by up to 60-90% in a half and only 'a little better' in a further fifth. Temporary bruising and diplopia (lasting 2 weeks) was reported in 12% (2/17). Conclusion: We report our outcomes for BoNTA to the palpebral lobe of the lacrimal gland in patients with lacrimal outflow obstruction epiphora seeking alternatives to surgery. This data provide further evidence for informed consent and for commissioning organisations considering the funding of this treatment.

Comparison of botulinum toxin-A injection in lacrimal gland and conjunctivodacryocystorhinostomy for treatment of epiphora due to proximal lacrimal system obstruction

“…26 Several different doses and concentrations of BTA injection have been published in the literature (2.5-60 U). 4,[7][8][9][10][11][12][13][14][25][26][27][28] Higher doses seem to have no additional benefit in terms of efficacy and duration. 7,9 Wojno reported 63% improvement with 2.5U of BTA in patients with lacrimal obstruction, but 37% needed an additional 2.5U.…”

“…However, there are a few reports that indicate injection of BTA in the lacrimal gland for lacrimal apparatus obstruction. 4,8,14,15 BTA injection in the lacrimal gland is devoid of the risks and complications of an invasive surgery and general anesthesia. Injection can be performed in an outpatient clinic.…”

“…4,[8][9][10][11][12][13][14] Transconjunctival injection in the palpebral lobe of the lacrimal gland is usually preferred due to the ability to directly visualize the lacrimal gland during injection. 4,7,8,[11][12][13][14][25][26][27] However, transcutaneous injection in the orbital lobe was also reported. 9,10,28 Montoya et al 12 injected 20 U Dysport initially via transcutaneous route but later progressed to transconjunctival route because of the confidence that the entire amount of BTA was directly delivered to the lacrimal gland.…”

“…Upper eyelid was everted over Desmarres eyelid retractor. Patients were asked to look inferomedially and injection of 4 units of BTA, which was arbitrarily chosen under the guidance of previous studies, [8][9][10][11][12][13][14] via 30-gauge tuberculin syringe was performed in the palpebral lobe under direct visualization transconjunctivally. Tobramycin 0.2% eye drop was applied as a single dose after the injection.…”

“…BTA injections in patients with epiphora owing to obstruction of lacrimal apparatus have been reported in a few reports. 4,8,14,15 In this article, we investigated and compared the efficacy of C-DCR and BTA injection in the lacrimal gland for treatment of epiphora owing to proximal lacrimal system obstruction.…”