BOTULINUM TOXIN: FROM A TO Z
Leonid Skorin, Jr., OD, DO, FAAO, FAOCO
BOTULINUM TOXIN
 7 different neurotoxins
 Produced by bacteria Clostridium botulinum
 Type A – Botox (Allergan)
Type B – Myobloc (Elan)
 Inhibits release of acetylcholine at neuromuscular junction
 No direct muscle damage
BOTOX
 100 units of botulinum toxin
 Reconstituted with sterile, nonpreserved 0.9% NaCl
 Use within 4 hours
 Initial effect at 3 days, maximal 1-2 weeks
 3 to 6 months duraction of action
MYOBLOC
 Premixed
 3 dosing volumes: 2,500u/0.5ml; 5,000u/1ml; 10,000u/2ml
TOXIN PRECAUTIONS
 Infection or inflammation
 Pregnancy or lactation
 ALS or myasthenia gravis
 Aminoglycosides
ANTIBODIES
 5% of those treated
 Increase time between injections
 Minimize overall dose
 Change neurotoxins
COSMETIC APPLICATION
 Facial wrinkling:
 gravitational redundancy
 loss of elasticity
 sleep creases
 dynamic facial lines
 Glabellar folds
 Lateral periocular rhytids
Skorin/ 1 of 4

Skorin/ 2 of 4
 Central forehead wrinkles
 Perioral lipstick lines
 Platysmal bands in neck
INJECTION TECHNIQUE
 Localize – frown and relax
 Inject adjacent muscle- NOT crease line
 Inject 1cm ABOVE bony supraorbital ridge
 Glabellar folds:
 5 injections (20u)
 2 each corrugator
 1 procerus
 Reduces resting tone of muscles
 Epidermis and dermis remodeled
NEURO-OPHTHALMIC APPLICATION
 Dystonias – involuntary sustained or spasmodic patterned repetitive muscle contractions
 Aberrant regeneration
 Acquired nystagmus
 Spasm of near reflex
BENIGN ESSENTIAL BLEPHAROSPASM
 Neurochemical etiology: adrenergic variability
 Bilateral eyelid spasms
 Two-thirds female, mean age 56
 Aggravated by stress
 Reduced by sleep
 Functional incapacitation – 10%
MEIGE SYNDROME
 Idiopathic orofacial dystonia
 BEB with lower facial involvement
 Lip pursing
 Tongue protrusion
 Involves speech
 Trismus (lockjaw)
BREUGHEL SYNDROME
 Idiopathic oromandibular dystonia
 BEB with lower facial, mandibular, cervical involvement
 Contraction of jaw
 Widely opened mouth

SEGMENTAL CRANIAL DYSTONIA
 BEB with several cranial nerves involved
APRAXIA OF LID OPENING
 Persistent contraction of pretarsal orbicularis
 Inhibition of levator muscle
 7% of BEB have ALO
ABERRANT REGENERATION AND SYNKINESIS
 Post- Bell’s palsy
HEMIFACIAL SPASM
 Muscles innervated by facial nerve
 Unilateral
 Continues during sleep
 More common in women
 Microvascular compression
 Jannetta procedure – 80% cure rate
 Neuroimaging required
OTHER OCULAR CONDITIONS
 Strabismus
 Eyelid retraction
 Spastic entropion
 Corneal exposure
NON-OCULAR INDICATIONS
 Spasmodic cervical dystonias
 Writer’s cramp, musician’s cramp
 Spasmodic dysphonia
 Spasticity of MS, CP, stroke
 Spasms of rectal sphincter
 Bladder dyssynergy
 Tremors, tics
 Palmar hyperhidrosis
BOTULINUM TOXIN FOR HEADACHE
 Migraines
 Tension-type headache
 Chronic daily headache
 Cervicogenic headache
 Cluster headache
MECHANISMS OF ACTION
Skorin/ 3 of 4

Skorin/ 4 of 4
 Reduction in peripheral pain
 Indirect:
 reduced muscle contractions
 reduced mechanoreceptor stimulation
 reduced afferent signals – decreased brainstem nociceptive stimulation
 Direct effect on peripheral sensory nerves
 Inhibit release of neuroactive substances
 Block extracranial inflammatory responses
CANDIDATES FOR BOTULINUM INJECTION
 Headache refractory to preventive treatment
 Patient preference
 Noncompliance with oral medications
 Contraindications to standard prevention
 Adverse events from standard prevention
 Coexisting jaw, head or neck muscle spasm
STRATEGIES FOR INJECTION
 Fixed-site:
 fixed symmetric sites
 best for migraine
STRATEGIES FOR INJECTION
 Follow-the-pain:
 adjust to symptoms
 best for tension-type
STRATEGIES FOR INJECTION
 Combination:
 fixed-site and follow-the-pain
 inject areas that are tender and consistently symptomatic
ADJUNCTIVE THERAPY – OSTEOPATHIC MANIPULATION
 Cranial
 Cervical Spinal
 Muscle energy:
 reciprocal inhibition
 postisometric relaxation
 active and passive stretching
 Positional release
 strain-counter strain
 functional
 myofascial release