Can Botox (Botulinum toxin) be used to treat eyelid drooping (ptosis)?

Botulinum Toxin (Botox) for Eyelid Ptosis

Botulinum toxin is not recommended as a treatment for eyelid ptosis (drooping); rather, it can cause ptosis as a side effect when used for other indications and can be intentionally used to create protective ptosis in specific clinical scenarios. 1

Understanding Botox and Ptosis

Botox as a Cause of Ptosis

• Botulinum toxin injections in the periocular region can cause temporary ptosis as an unintended side effect
• This occurs when the toxin diffuses from the injection site to the levator palpebrae superioris muscle, which is responsible for lifting the upper eyelid 2
• The incidence of ptosis following cosmetic Botox injections around the eyes can be as high as 37% in some patient populations 3

Intentional Use of Botox for Protective Ptosis

Botulinum toxin can be deliberately injected to create a protective ptosis in specific clinical scenarios:

• As an alternative to surgical tarsorrhaphy (eyelid suturing) in patients with corneal exposure issues 4
• When injected directly into the levator palpebrae superioris muscle at a dose of 5 units, it can create a temporary ptosis lasting approximately 46 days (range 1-206 days) 4
• This approach allows underlying corneal conditions to heal while avoiding surgery

Management of Botox-Induced Ptosis

When ptosis occurs as an unwanted side effect of cosmetic Botox injections, several approaches may be considered:

1. Conservative management:

   • Most cases resolve spontaneously as the toxin effect wears off (typically 2-12 weeks)
   • Patients should be counseled about the temporary nature of the condition

2. Pharmacological interventions:

   • Topical oxymetazoline HCl 0.1% (Upneeq) can help temporarily improve ptosis 2
   • Pretarsal botulinum toxin injections have been reported to help counteract ptosis in severe cases 2

3. Preventive techniques:

   • When treating patients with a history of ptosis after Botox, modified injection techniques can be used
   • Injecting into the superior middle aspect of the corrugator muscle rather than the common site above the medial eyebrow head may reduce ptosis risk 5
   • Human botulinum immune globulin (3.2 × 10^-3 IU per unit of Botox) injected into the same tissue site within 4 hours can block toxin effect 3

Clinical Considerations and Pitfalls

Differential Diagnosis

When evaluating eyelid drooping, consider other causes besides Botox effect:

• Myasthenia gravis (presents with variable ptosis that worsens with fatigue) 6
• Neurological conditions
• Mechanical ptosis from eyelid masses or swelling
• Age-related aponeurotic ptosis

Important Caveats

• Ptosis that persists beyond the expected duration of Botox effect (3-4 months) should prompt further neurological evaluation 6
• Botulinum toxin is not FDA-approved specifically for treating true ptosis
• When using Botox in the periocular region, proper technique and anatomical knowledge are essential to minimize ptosis risk

Conclusion

Botulinum toxin is not a treatment for eyelid ptosis but rather a potential cause of it. The only therapeutic application of Botox for ptosis is when it's intentionally used to create a protective ptosis as an alternative to surgical tarsorrhaphy. Practitioners should be aware of prevention strategies and management options when ptosis occurs as an unwanted side effect of cosmetic Botox treatments.