What to do if one upper eyelid sags after Botox (Botulinum toxin) injections?

Management of Eyelid Ptosis After Botox Injection

For upper eyelid ptosis that occurs after Botox injection, the most effective approach is to wait for spontaneous resolution while using apraclonidine eye drops for temporary relief of symptoms.

Understanding Post-Botox Ptosis

Ptosis (drooping of the upper eyelid) is a recognized complication of botulinum toxin injections, particularly when administered in the forehead, glabella, or periocular regions. This occurs when the toxin diffuses to the levator palpebrae superioris muscle, which is responsible for upper eyelid elevation.

Evaluation

When a patient presents with post-Botox ptosis:

• Assess the severity of ptosis and its impact on vision
• Determine the time since injection (important for prognosis)
• Check for other associated symptoms (dry eye, tearing)
• Examine for any pre-existing eyelid or orbital conditions

Treatment Algorithm

1. Observation and Reassurance

• Most cases of post-Botox ptosis are temporary and self-limiting
• Typically resolves within 4-6 weeks as the effects of botulinum toxin gradually wear off 1
• Reassure the patient about the temporary nature of this side effect

2. Pharmacological Management

• Apraclonidine 0.5% eye drops (first-line treatment)
  • Acts as an alpha-adrenergic agonist that stimulates Müller's muscle
  • Can temporarily elevate the upper eyelid by 1-2 mm
  • Apply 1-2 drops up to three times daily as needed for symptomatic relief
  • Response to apraclonidine can help predict recovery timeline 2
    • Responders likely to resolve within 4-6 weeks
    • Non-responders may have more prolonged ptosis (potentially lasting months)

3. Supportive Measures

• Avoid additional botulinum toxin injections in the affected area until complete resolution
• Consider mechanical eyelid taping for severe cases that significantly impair vision
• Use preservative-free lubricating eye drops if dry eye symptoms develop

Special Considerations

Persistent Ptosis

• In some cases, ptosis may persist beyond the expected 4-6 week timeframe
• Studies have documented cases lasting from 6 weeks to 13 months 2
• If ptosis persists beyond 3 months, consider referral to an ophthalmologist for comprehensive evaluation

Contraindications

• Avoid apraclonidine in patients with:
  • Known hypersensitivity to the medication
  • Monoamine oxidase inhibitor therapy
  • Severe cardiovascular disease

Follow-up Recommendations

• Initial follow-up within 1-2 weeks to assess response to treatment
• If using apraclonidine, monitor for side effects (conjunctival blanching, allergic reactions)
• Consider discontinuing apraclonidine after 2-3 weeks if no improvement is seen

Prevention of Future Episodes

For patients who have experienced ptosis after Botox:

• Consider lower doses in subsequent treatments
• Inject at least 1 cm above the orbital rim for forehead treatments
• Avoid injections in the lateral and mid-pupillary areas of the brow
• Use more concentrated preparations with smaller volumes

When to Refer

Refer to an ophthalmologist if:

• Ptosis persists beyond 3 months
• There is significant visual impairment
• Patient fails to respond to conservative management
• There are concerns about other underlying eyelid or orbital pathology

Remember that while botulinum toxin-induced ptosis can be distressing for patients, it is almost always temporary, and most cases resolve completely with time and supportive management.