|
|
||||||||
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
Med Hypotheses. 2007 Jan 18; [Epub ahead of print] L.A.
Pain Clinic, Hawthorne, California Med Hypotheses. 2005;65(3):559-69 Pain Med. 2004 Jun;5(2):229-30
|
Pain
Med. 2005 Mar-Apr;6(2):149-51 Key words: Botulinum toxin; Ptosis; Migraine; Apraclonidine. Introduction:
Botulinum toxin Type A injection has been used for the CASE REPORT A forty
seven year old woman with chronic migraine had injections of Botulinum toxin
Type A as part of a treatment regimen. 0.1 ml of Lidocaine 1% with 2.5
units of the Botulinum toxin was injected into each muscle belly of the
bilateral Orbicularis Oculi, bilateral Corrugator Supercillis, and the
midline Procerus muscles. 0.1 ml of Lidocaine 1% with 2.5 units of the
Botulinum toxin was injected into five sites in the Frontalis muscle, and
five sites in each Temporalis Muscle. A total of 50 units of the Botulinum
toxin and 2 mls of Lidocaine 1% were injected. One week later, the patient was seen in the clinic with a complaint of weakness in opening the right eye. She stated that the weakness started three days after the Chemodenervation procedure with Botulinum toxin. On examination the patient had ptosis in the right eye with an inability to fully open the eye on command. The Margin Reflex Distance (MRD) on the right eye was 2 mm, and 5 mm on the left eye. The normal MRD for this patient was 6 mm in both right and left eyes. The patient was advised that the ptosis would be temporary. No medications were prescribed. Five days later, the patient returned to the clinic stating the weakness in the right eye had not resolved and she also had weakness in opening her left eye. On examination, the patient had ptosis of both eyes. The Margin Reflex Distance in both right and left eyes was 2 mm. The ptosis was associated with pain, excessive lacrymation, and conjunctiva injection in both eyes. The patient was prescribed the following medications. Apraclonidine 0.5 % ophthalmic solution 1-2 drops to be instilled in both eyes q 8hr to treat the ptosis, and dexamethasone 0.1% / tobramycin 0.3% ophthalmic suspension instilled in both eyes q 4hr to treat the conjunctival inflammation. The patient
returned to the clinic, five days after treatment was started. She
stated that her eye opening improved one day after commencing treatment, and
by the third day excessive lacrymation and conjuctival injection were
completely resolved. On examination there was only mild ptosis in the right
eye (MRD 4 mm) and the left eye ptosis had resolved (MRD 6 mm). The
conjunctiva was clear in both eyes. On re-evaluation nine days later the
right eye ptosis was completely resolved and MRD in bilateral eyes was 6 mm. Discussion – Prevention of ptosis requires care during injection and in the post-procedure period. When injecting Botulinum toxin, care should be taken not to inject the lower Frontalis or Orbicularis oculi muscles at sites that are lateral to the mid-pupillary line. And also the needle should be pointing superiorly away from the orbit. These are to prevent the toxin from tracking downward and denervating the muscles that raise the eyelid, resulting in ptosis. The Levator Palpebrae Superioris and Superior Tarsal muscles elevate the eyelid. The Levator Palpebrae Superioris is a voluntary muscle innervated by the Oculomotor nerve, while the Superior Tarsal (Müller) muscle is a smooth muscle innervated by sympathetic nerves that have preganglionic cell bodies in the upper thoracic levels of the spinal cord and postsynaptic cell bodies in the superior cervical ganglion. The Superior Tarsal muscle has its origins from the undersurface of the Levator Superioris. Approximately 12 mm length, it inserts superiorly on the tarsal border and elevates the upper lid approximately 2 mm. At rest, the lid is just below the top part of the iris (the colored part of the eye). This is measured with the patient looking straightforward with the head vertical. The lid position is measured relative to the visual axis using the margin reflex distance (MRD). This is the distance from the eyelid margin to the corneal light reflex with the patient looking straight ahead at a penlight. Normal MRD is usually greater than 2.5 mm. Ptosis due to Botulinum toxin injection was successfully reversed with apraclonidine ophthalmic solution. Apraclonidine an alpha-adrenergic receptor agonist possibly reversed the ptosis by directly stimulating the sympathetic innervations of the Superior Tarsal muscle. There is currently no treatment for Botulinum toxin-induced ptosis. Patients who suffer such a complication have to wait for several weeks until the effects of the toxin wear off. This case report suggests that apraclonidine can provide a reversal option for physicians and their patients.
References 1.Loder E, Biondi D. Use of Botulinum toxins for chronic headaches: a focused review. Clin J Pain 2002 Nov-Dec; 18(6 Suppl): S 169-76. 2. Sanchez-Prieto J et al. Botulinum toxin A blocks glutamate exocytosis from guinea pig cerebral cortical synaptosomes. Eur J Biochem 1987 Jun15; 165(3): 675-81 3.Ray P,
Berman JD, Middleton W, Brendle J. Botulinum toxin inhibits arachidonic acid
release associated with acetylcholine release from PC12 cells. J Biol Chem 1993 May 25; 268(15): 11057-64. 4.
Hardebo JE, Suzuki N, Ekbald E, Owman C. Vasoactive intestinal polypeptide
and acetylcholine coexist with neuropeptides Y, dopamine-beta-hydroxylase,
tyrosine hydroxylase, substance P or calcitonin gene-related peptide in
neuronal subpopulations in cranial parasympathetic ganglia of rat. Cell Tissue Res 1992 Feb; 267(2): 291-300. 5.
Omoigui S. The Biochemical Origin of Pain: How a new law and new drugs
have led to a medical breakthrough in the treatment of persistent pain.
Hawthorne, CA. State-of-the-Art Technologies Publishers, 2002. p.
78-79 6. Imamura K, Spriggs D, Ohno T, Kufe D. Effects of Botulinum toxin type D on secretion of tumor necrosis factor from human monocytes. Mol Cell
Biol 1989 May; 9(5): 2239-43. 7. Jose Morales et al. Ocular Effects of Apraclonidine in Horner Syndrome. Arch
Ophthal. 2000;118:951-954. 8. Benabent EC, Garcia Hermosa P, Arrazola MT, Alio y Sanz JL. Botulinum toxin injection without electromyographic assistance. J Pediatr Ophthalmol Strabismus. 2002 Jul-Aug;39(4):231-4.. 9.
Redaelli A, Forte R. How to avoid brow ptosis after forehead treatment with
botulinum toxin. J Cosmet Laser Ther. 2003 Dec;5(3-4):220-2. |
