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Injection Techniques with Botulinum Toxin
in the Treatment of Blepharospasm

Mark Stacy, M.D.
Associate Professor of Neurology
Duke University Medical Center

The development of Botulinum Toxin (BoNT), a muscle paralyzing agent from the bacteria, Clostridium botulinum, has produced major advances in the treatment of dystonia (such as blepharospasm or torticollis), hemifacial spasm, tremor, tic disorders, and a number of other conditions - including those annoying crow's feet! In 2000, because of the wide variety of injection techniques in treating blepharospasm, a group of ophthalmologists and neurologists recognized as "experts" by the BEBRF were surveyed for injection locations and amount of toxin injected on initial and average visits. Each of the respondents indicated dosages, dilutions, and number of injections for a typical patient. Although there were some differences in the sites for injection between injectors with ophthalmology and neurology training, these differences have declined. The five sites per eye identified in the figure are the most common locations for toxin injection. Other sites will vary with the presentation, and the experience of the physician. The purpose of this handout is to assist patients and physicians with discussion points to tailor future toxin therapy.

Toxin Dosage:

Toxin dosage varies from patient to patient, and units vary from toxin to toxin. Currently, there are four commercially available toxins. The three BoNT-A include Botox®, Dysport® and Xeomin®; Myobloc®/Neurobloc® is the only available a B-type toxin. While the injection techniques will not change with these toxins, dosages will differ. It is therefore important to know the brand name, not just A or B, of toxin used at each injection session.

Initial dosage range for each toxin is listed in the table. Further dosage adjustment may be made for size of the patient, severity of the symptoms, and prior response to therapy. Ideal dosing should produce a benefit within one week of the session, and a total duration of benefit of approximately twelve weeks. In instances where side effects, such as lid drooping (ptosis), double vision (diplopia), or tearing occurs, injection with less toxin or in a slightly different location may allow more effective response.

Each of the A-type toxins requires reconstitution with preservative free, normal saline. Most experienced injectors reconstitute with 1 cc of solution, thus with Botox® and Xeomin®, 0.01 cc = 1 unit, and Dysport®, 0.01 cc = 5 units. Myobloc®/Neurobloc® may offer some convenience of use, because this preparation does not require reconstitution and may be stored in the refrigerator. The dilution for this toxin is 0.01 cc = 50 units. It is difficult to convert from one toxin to another on the basis of dosage ratio, and each compound should be treated as a unique toxin.

Injection Diagram for Treating Blepharospasm

face diagram

The 10 most recommended injections sites are marked on the diagram. Injection of the corrugator supercilii m is often helpful in patients with furrowing around the eyebrows. Injection under the skin of the upper lids is more effective than injections higher in the orbit (off the lid margin). Injections to the lower lids may be off the lower lid margin, and usually just to the lateral site to avoid tearing.

Other injections sites include the lateral obicularis oculi m. - particularly if deep furrows in the skin indicate spasm in this area. With midline brow furrowing, injection of the procerus may be helpful. Nasal movements may respond to levator labii superioris nasi m., but this injection may cause tearing and lip weakness.

Relative dosages for Botulinum Toxina

Toxin  Frontalis  Upper Lid Lower Lid  Other  Recommended Dosage/eyeb
  Site Total Site Total Site Site  
 BoNT -
 Type A
   Botox® 5 10 5 10 8 5 30-50
   Dysport® 15 30 15 30 25 15 100-120
   Xeomin® 5 10 5 10 10 5 35
 BoNT -
 Type B
   Myobloc® 150 300 150 300 200 200 1,000-2,500

a This table is adapted from Stacy M, Handbook of Dystonia. Informa Press 2006.

b Recommended dosages are obtained from the Package Insert from countries that have approved the toxin. They are listed as a per eye dosage. Product approvals vary from country to country.

This article originally appeared in the Benign Essential Blepharospasm Research Foundation Newsletter, Volume 26, Number 3, page 13 (2007). Note that the paragraph beginning, "Each of the A-type toxins..." has been revised from that appearing in the newsletter to correct numerical errors.

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