Botulinum neurotoxin blazon A (BoNTA) is broadly acclimated in artful anesthetic as analysis for glabellar lines. BoNTA blocks the absolution of the neurotransmitter acetylcholine, consistent in blockage of neuromuscular manual and paralyzing the ambition muscle. Therefore, bang of BoNTA can abate beef activities, abatement beef tension, and bland facial wrinkles.1,2 BoNTA analysis is associated with a low amount of adverse effects. In the better multidepartment attendant abstraction conducted to date, Kim et al3 appear that the accident of adverse contest afterwards BoNTA bang was alone 3.73%.
Most adverse contest accompanying to BoNTA bang are accessory and transient, and composed of eye disfiguration and eyes blockage. Affection commonly present about 2 weeks afterwards bang and abide for about 15 canicule (range, 7–85 days).4,5 To date, however, there is no accord on the accident of and analysis for all types of adverse furnishings afterwards bang of BoNTA.
Although ptosis is a accepted ancillary aftereffect of BoNTA injection,3 eyelid edema is a beneath accepted adverse aftereffect of BoNTA treatment, and few studies accept brash its etiology, analytic course, and analysis outcomes. Herein we present a case with mutual periorbital abscess and erythema afterwards BoNTA injection. Absolute continuance of aftereffect was 16 weeks.
A 59-year-old woman with a history of well-controlled asthma accustomed BoNTA analysis to bland wrinkles on her forehead, glabella, and corners of her eyes (crow’s feet). Physical assay appear thick, triangular-shaped eyelids with infolding of the high eyelid (Figure 1A).
Therapy compriss BoNTA (BOTOX®, Allergan, Inc, Irvine, CA, 100 U in 4 mL accustomed saline) injections to the forehead (12.5 U), glabella (12.5 U), and eye corners (crow’s feet) (12.5/12.5 U). A 5-point bang was performed to glabella and eye corners.
At 3-day follow-up, the accommodating presented with painless, nonpruritic, mutual periorbital abscess and erythema. Physical assay appear no affirmation of bark rash, tenderness, or conjunctival congestion. The basic analysis was a bounded allergic acknowledgment to BoNTA. A contemporary corticosteroid (Rinderon® oph ointment, Shionogi, Taiwan) was administered to the bloated periorbital arena 2 times per day for 3 days. However, the medication did not aftereffect in evidence abatement (Figure 1B).
Based on the analytic course, we accepted that eyelid edema was best acceptable due to broken venous and aqueous acknowledgment acquired by bargain beef accent rather than allergic acknowledgment or infection. We brash the accommodating to administer hot pads over her eyes, blink frequently, and beating the afflicted breadth in adjustment to access venous return. No antibiotics or antihistamines were prescribed. The patient’s eyelid edema eventually bound 2 weeks afterwards (Figure 1C).
At 4-month follow-up, the accommodating requested an added advance of BoNTA therapy. This time, we adapted the dosage to bisected of the original. We instructed the accommodating to blink frequently, abnormally in the aboriginal morning afterwards abiding venous antithesis during sleep, and to beating the periorbital breadth to access venous return. No adverse furnishings were acclaimed afterwards the additional analysis and the accommodating appear a satisfactory aftereffect (Figure 2A,B).
The best accepted complications amid patients who accept BoNTA to eye bend for analysis of crow’s anxiety are bruising, dry eye, corneal exposure, diplopia, ectropion, lid retraction, added lid malpositions, and an absurd smile (caused by the advance of adulteration to the zygomaticus major).6 Little is accepted about the development of periocular eyelid edema afterwards botulinum adulteration injection. In a attendant abstraction of 5310 botulinum adulteration bang treatments amid 1819 patients, alone 2 (0.04%) patients developed eyelid edema.3 In a meta-analysis of BoNTA bang for the analysis of glabellar curve or crow’s anxiety in 1678 patients, Brin et al4 begin that the average time of eyelid edema access was 5 canicule (range, 2–106 days) and that the average continuance of affection was 15 canicule (range, 7–85 days). They additionally begin that the accident of treatment-related eyelid edema (1.4%, 21/1492) was decidedly college amid patients who accustomed 20 U botulinum adulteration A bang than amid those who accustomed placebo. Furthermore, the advisers acclaimed that Asian populations are at greater accident for BoNTA-induced eyelid edema than Caucasian populations (3.1%, 8/260 vs 0.7%, 4/614).4
Eyelid edema is generally due to allergy, infection, or trauma, but can be acquired by poor venous or aqueous acknowledgment to the eyelid or decreased beef tone. Definitive analysis can be fabricated by compassionate the apparatus and archetype the analytic advance if there is no acknowledgment to antiallergic treatment. Procedural and possibly alike bounded adverse furnishings are acceptable to be related, to some extent, to injector experience, and are appropriately accepted to abatement with the cardinal of analysis cycles. We begin that again treatments are associated with a lower accident of eyelid ptosis, eyelid acoustic disorder, and eyelid edema. Similar allegation were appear by Brin et al.4
Multiple anatomy are complex in the blinking reflex. In the high eyelid, the levator palpebrae superioris, which divides into an aponeurosis and a added allocation that contains the Müller’s (superior tarsal) muscle, is amenable for eyelid retraction. The orbicularis oculi is the capital beef that controls closing of the eyes. Pretarsal and posttarsal plexuses accommodate the venous arising of the eyelid, which included ophthalmic attitude and the veins that cesspool the forehead and temple. Preauricular and parotid nodes cesspool the lymphatics from the crabbed articulation of the lids. Submandibular lymph nodes cesspool the centermost ancillary of the lids.7
In our case, eyelid edema access was 3 canicule afterwards 12.5 U botulinum adulteration injections anniversary to the glabella and mutual eye corners. The absolute continuance of analysis was 2 weeks. Kim et al3 appropriate that the bounded advance of adulteration into adjoining beef and tissue ability be amenable for the development of eyelid edema. Brin et al4 appropriate that the alleviation of the basal beef accent afterwards periocular bang with BoNTA and its accessory furnishings on interstitial aqueous mechanics were the capital affidavit for the development of eyelid edema. Based on the allegation in this study, we adduce that the apparatus administering the development of eyelid edema afterwards BoNTA bang ability be the accumulated aftereffect of venous or aqueous antithesis accompanying to the alone eyelid anatomy and decreased beef accent acquired by bounded circulation of neurotoxin, which lessens the interstitial aqueous acknowledgment adjoin gravity. The apparatus of eyelid edema is altered from ptosis, which is acquired by adventitious alleviation of the levator muscle.4
Eyelid edema due to broken automated venous acknowledgment is added accepted in Asians than Caucasians.4 In Asians, there are beneath coarse accessories amid the levator aponeurosis, orbicularis, and bark of the eyelid. This after-effects in a abridgement of supratarsal bulge and beneath eyelid retraction for venous arising while blinking.8,9 The admixture of the levator aponeurosis and alternate septum is afterpiece to the eyelid margin, causing the appropriate aggrandizement in Asian eyelids.9,10 This aggrandizement compresses the attitude and obstructs venous return, which is already impeded by force (Figure 3A,B).
Another appropriate of Asian eyes is eyelid hooding (dermatochalasis). Patients with dermatochalasis tend to accept beneath adaptable fibers and greater breakdown of collagen networks, which advance to accessory lymphostasis and eyelid edema.11 Accident of dermatochalasis increases with age,12 and was additionally acclaimed in our patient, who was 59 years old. The balance of skinfolds additionally hinders venous acknowledgment (Figure 1A). Based on the automated factors administering eyelid edema afterwards periocular BoNTA injection, we advance that patients abide assay of the action and accent of the orbicularis oculi and levator palpebrae superioris anatomy afore analysis as antitoxin strategies. Doses of BoNTA and bang credibility should be adapted in patients at accident for developing periorbital edema (Table 1).
Although rare, periorbital edema due to BoNTA bang is self-limiting and does not crave medical treatment. As reflected from the case, edema can be managed by appliance of hot pads over the eyes, accepted blinking in the morning, and self-massage of the afflicted breadth in adjustment to access venous return. Antitoxin strategies accommodate assay of the action and accent of the orbicularis oculi and levator palpebrae superioris anatomy afore treatment. Patients at accident for edema such as Asian ethnicity, dermatochalasis, and poor periocular beef accent should accept bisected the accepted dosage of BoNTA.
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