As the world of cosmetic medicine continues to expand, the role of aesthetic services in ophthalmology will follow suit. One of the major players in expanding your aesthetic practice is the introduction of Botox, otherwise known as botulinum toxin.
Reviewing the basics of Botox in healthcare
Neurotoxins are the most common non-invasive aesthetic procedure in the United States. Although most are familiar with onabotulinumtoxinA (Botox), there are three other official FDA-approved neurotoxins: abobotulinumtoxinA (Dysport), prabotulinumtoxinA-xvfs (Jeuveau), and incobotulinumtoxinA (Xeomin).
Common applications of botulinum toxin in ophthalmology for medical purposes include benign essential blepharospasm, hemifacial spasm, myoclonic disorders, and strabismus. Botox has also been used to temporarily treat lid malposition, such as entropion with overriding orbicularis. In fact, the first clinical application of botulinum toxin injection was performed by an ophthalmologist who injected botulinum toxin to treat strabismus.
Through inhibition of acetylcholine release at the neuromuscular junction, botulinum toxin can cause paralysis of muscle tissues. Botulinum toxin is produced by fermentation of the bacterium Clostridium botulinum.1,2 At very high doses, the toxin can lead to serious illness.3 However, local injections of commercially-produced neurotoxins do not reach anywhere near these levels and have been found to be very safe and effective.
Botox is injected intramuscularly directly into the region of the desired action, and the dose can be expressed in terms of units (U) of biological activity. The effect of Botox generally lasts between 3 to 4 months. Upon initial injection, it may take 1 to 2 weeks to observe the desired effect. In some cases, it may take up to 30 days.
The benefits of bringing Botox to your ophthalmology practice
In terms of use and relevancy, botulinum toxin has traditionally been a common treatment modality for oculoplastic surgeons. Some oculoplastic surgeons have even expanded their scope of therapeutic Botox to include conditions such as hyperhidrosis and migraine headaches.4,5 For the general ophthalmologist, Botox presents a unique opportunity to introduce a simple but effective aesthetic service into a practice.
In my practice model, we offer many non-surgical services, from skincare to fillers and various laser treatments. We have discovered that Botox is by far the best gateway to introduce patients to our other aesthetic services. This is likely due to commercial and wide-based marketing campaigns that have led Botox to become a household name.
In many cases, first-time patients may not know the purpose or the exact mechanism of neurotoxin injections. Many patients are anxious and often seek clarification regarding the safety profile of neurotoxin injections. This presents an opportunity for education and expanding knowledge of some of your other services that may be just as, or more suitable, to the patient’s needs and goals.
Clinical pearls for administering Botox
There are many clinical benefits to treatment with Botox, particularly in patients with benign essential blepharospasm (BEB) and hemifacial spasm (HFS). Botox can improve the quality of life for many patients with HFS and BEB. Obtaining a good history is important for differentiating between the two.
Treating benign essential blepharospasm with Botox
Benign essential blepharospasm will usually present bilaterally and is not present during sleep. Patients sometimes complain that the contractions are so strong that they cannot see while driving or reading.
Although most often unilateral, eyelid myokymia can present similarly to BEB. Thus, you want to ask about the history of any ocular surface disease, caffeine intake, stressors, and sleep hygiene, as these are common causes of eyelid twitch. Eyelid myokymia usually resolves spontaneously and is most often managed with lifestyle modification. Botulinum toxin injection can be used in persistent cases.
Treating hemifacial spasms with Botox
HFS is characterized by unilateral tonic-clonic involuntary contractions, most often starting with the orbicularis oculi or orbicularis oris muscle and eventually spreading to other muscles in the distribution of the facial nerve.6
Spasms often are present during sleep. In patients with HFS, it is important to consider brain imaging as it has been associated with compressive lesions (both intra-and-extracranial), stroke, and demyelinating diseases. Vascular compression of the facial nerve root exit zone has been reported as the most commonly known cause.
Risk factors include hypertension (HTN), female gender, older age, and Asian background.7 Cases of bilateral hemifacial spasm are rare and may require a more extensive workup. Amongst botulinum toxin products, only Botox is FDA-approved for the treatment of hemifacial spasms.5
A careful examination, including a complete ophthalmic exam and characterization of spasm severity, location, and frequency, is imperative. Once the decision to administer Botox treatment has been made, it is safe to start with a general or “naive” pattern.
It is important to pay careful attention to anatomical regions that are most symptomatic and the extent and distribution of the pathology. I have seen various concentrations and patterns of administration for Botox amongst different providers, many of which were effective in their own respects.
Botox preparation, storage, and injection
Each botox vial contains either 50 units (U), 100 U, or 200 U of Clostridium botulinum toxin type A-haemagglutinin complex as the active ingredient. Note that 50 U vials are labeled for cosmetic use only. It also contains human albumin and sodium chloride.8
According to Allergan, the recommended administration for HFS, BEB, and other 7th nerve disorders, is as follows:
“1.25 U to 2.5 U (0.05mL to 0.1mL) for each muscle injected. The initial effect occurs within 3 days, with the maximum muscle relaxation reached within 1 to 2 weeks and lasting approximately 3 months. After this, you should return for a repeat dose. The total maximum dose in a 2-month period should not be more than 200 U.”5
Preparing the Botox injection
The first step before the injection is to reconstitute each vacuum-dried vial of BOTOX. This is done with sterile, preservative-free 0.9% Sodium Chloride Injection, USP.
Insert the proper amount of diluent in an appropriate size syringe, and slowly inject the diluent into the vial. The vial must be discarded if a vacuum does not pull the diluent into the vial. Next, carefully mix BOTOX with the diluent by rotating the vial. Record the date and time of the reconstitution in the space on the label. BOTOX should only be used within 24 hours after reconstitution.
During this time, unused reconstituted BOTOX should be stored in a refrigerator (2° to 8° Celsius) for up to 24 hours until the time of application. BOTOX vials are labeled for single-dose only. Any unused portion should be discarded. It is important to note that for Botox and Xeomin, identical dilution/units can be used, however, that does not apply to Dysport.
Mixing Botox with bacteriostatic saline
In my practice, I have found success with a simple 1:1 mixture of Botox to bacteriostatic saline. This is effective and gives me a duration of about 3 to 4 months. Additionally, mixing with bacteriostatic saline (a sterile, isotonic solution of sodium chloride in water and benzyl alcohol added as a bacteriostatic preservative) is reported to be less painful for patients.
A higher concentration of toxin means you would inject less volume to reach a given number of units. The less volume you inject, the more concentrated the toxin effect is without affecting adjacent structures. Conversely, a lower concentration allows you to inject a higher volume and get a larger area of action.
How to reconstitute the Botox
When you reconstitute the Botox, it is important to know how many units of product are in the vial. For functional injections, make sure that you obtain the vials labeled for medical use, as cosmetic bottles of Botox vials are separate formulations.
Medical Botox usually comes in a 100 or 200 U vial. A 1:1 mix means you use 1ml of saline for a 100-unit vial for a concentration of 100 units/mL. A 50-unit vial 1:1 mix means you are using 0.5ml of saline to achieve that same 100 units/mL concentration. I have seen similar success with the same 1:1 dilution for cosmetic Botox.
Patient education on medical Botox for ocular conditions
Prior to entering the room, we provide the patient with an anatomical photo checklist of potential treatment areas to better understand what the patient is looking to achieve. This facilitates the process of ensuring we are meeting the patient's goals.
Marking prior to injection is helpful, having patients raise their brows, frown, and smile can help assess potential rhytids that can be treated. Taking photos prior to treatment is important and will help serve as a good comparison to post-procedure photos.
FDA-approved indications for cosmetic botox include:
- Moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity
- Moderate to severe lateral canthal lines associated with orbicularis oculi activity
- Moderate to severe forehead lines associated with frontalis activity8
Appropriate coding is also imperative, and using the updated local coverage data for botulinum toxin can be helpful. This information can be obtained from the medical coverage database located on the Centers for Medicare and Medicaid Services website.9
Table 1 outlines medical Botox dosage using 100 U and 200 U vials as examples.
| Diluent Added to 100 Unit Vial | Resulting Dose Units per 0.1mL | Diluent Added to 200 Unit Vial | Resulting Dose Units per 0.1mL |
|---|---|---|---|
| 1mL | 10 Units | 1mL | 20 Units |
| 2mL | 5 Units | 2mL | 10 Units |
| 4mL | 2.5 Units | 4mL | 5 Units |
| 8mL | 1.25 Units | 8mL | 2.5 Units |
| 8mL | 1 Unit | 8mL | 2 Units |
Table 1: Courtesy of Nathan K. Kanyinda, MD
The importance of pattern and location for Botox injections
In my practice, we have observed that in many cases, the pattern and location of injection are often more important than the amount administered. Some clinicians believe that more units equate to better clinical outcomes. However, in many circumstances, less is more if you can execute an effective pattern. This pattern can be developed over time as the patient returns for subsequent follow-up visits. However, it is important to note that a well-customized pattern may require more units per area treated to improve duration.
Once the desired outcome has been achieved, the pattern and number of units administered can now be saved into the patient's chart. Having a diagram of where you have injected and how much you have injected is important. A marking pencil can also be used beforehand to mark injection points consistent with your diagram. We find that using an insulin needle effectively minimizes discomfort and tracks the number of units being administered in real time.
If you are injecting multiple areas, it may be useful to have a syringe per area treated because the needle can become dull. If an insulin needle is not available, it is acceptable to use a 30-gauge needle on a 1ml syringe.
Analgesia during the Botox injection
Depending on the provider, there are different techniques for analgesia. There are injectors that do not use any methods for analgesia, while others provide some form of analgesia. It is important to explain to the patient that they may feel a pinprick.
There are, however, different sensitivity levels to pain, and the provider must be able to detect this. Methods such as pre-treatment numbing creams and ice compression have been shown to be effective. Vibration anesthesia devices can also be used to distract the patient from the injection.
Communicating Botox treatment expectations
Setting patient expectations is important, whether the patient is functional or cosmetic. In both cases, it may take follow-ups and further touch-ups to reach the desired effect. Furthermore, in a patient with very powerful spasms, the goal may be to reduce the severity rather than complete eradication.
Be sure to let your patient know that although some patients may see the effects starting anywhere from 1 to 2 weeks, it may take up to 30 days to see full effects. A 2-week follow-up is a good rule of thumb for assessment post-treatment.
Common side effects of Botox injections
Side effects can include bruising and swelling. Generally, these resolve quickly if they occur. Patients should not receive the medication if they are allergic to any of the basic drug ingredients, have an active infection in a muscle to be treated, or have myopathies such as myasthenia gravis or Eaton Lambert Syndrome.8
For the medical treatment of blepharospasm or hemifacial spasm, there is also the risk of lagophthalmos. Ptosis is another rare but possible complication seen in both cosmetic and medical approaches. These complications are self-limited but may be very bothersome to the patient.
Lagophthalmos can be managed with lubrication of the ocular surface and careful observation of the cornea. Ptosis can be treated with oxymetazoline hydrochloride ophthalmic solution 0.1%, an aesthetic eye drop that can lift the eyelid for a duration of 6 to 8 hours. Some literature has found that ptosis can also be treated with topical brimonidine.10
Getting started with Botox
For the provider interested in adopting Botox into their practice, it is important to consider attending a small course or reaching out to local reps for companies that produce FDA-approved neurotoxin injections.
Involving these pharmaceutical representatives is a great way to introduce the service to your staff and provide the educational content necessary to begin the process of becoming familiar with Botox. Once a commitment to obtaining the product is demonstrated by your practice, many of these companies will be willing to provide training sessions. These sessions should include the provider and all relevant staff members.
It is especially effective to offer some staff members the opportunity to volunteer as patients during these training sessions in exchange for free Botox. Your best advocates will be your technicians and front desk staff. If they are able to talk about their experience, this will greatly increase the confidence potential patients will have in your product.
In addition, company reps work with local spas and offices and will know what other providers are charging as well as average rates in your area.
Marketing and promotion for Botox services
Once you’re ready to launch your Botox service, you must commit to consistent marketing and promotion. Many patients are attracted to specials, deals, and packages. If you already have a large patient base and or listserv, it is best to start by informing your current patient base of your new service through an E-blast. It is also important to have posters and signs for your new product services in the exam and waiting rooms.
Take advantage of holidays to create unique events and evenings for your Botox specials. It may even be helpful to hire a team that specializes in marketing for aesthetic medicine.
Final thoughts on Botox in eyecare
Adding Botox to your current list of services can expand opportunities for the expansion of cash-based services and open doors for additional cosmetic and nonsurgical options. As ophthalmologists, we must understand and master not only the anatomy of the eye but also the periocular and facial anatomy.
This presents a unique opportunity for the ophthalmologist injector who is able to use their fine touch and knowledge of anatomy to administer botulinum toxin safely.
