Dr. Akshay Nair, N12639, Dr. Vandana Jain, Dr. Chhaya A Shinde, Dr. (Mrs ) Potdar Nayana Anil
Akshay Gopinathan Nair1,2
Vandana Jain1
Chhaya Shinde2
Nayana Potdar2
1- Advanced Eye Hospital & Institute, Navi Mumbai, India
2- LokmanyaTilak Municipal Medical College, Sion, Mumbai, India
No Financial Disclosures for any authors
Abstract:
Purpose:
To study outcomes of Botulinum Toxin A (BonTA) injections into the Lacrimal Gland (LG) in cases of epiphora and hyper-lacrimation.
Methods:
Retrospective, interventional case series of 14 patients who chose LG BonTA injections for epiphora/hyper-lacrimation.
Results:
14 patients (17 eyes) were treated with injections of BonTA (2.5-5U) in the palpebral lobe of the LG. A mean of 2 injections (range: 1-3) were given per eye. The most common indication was canalicular obstructions (6/14;43%). The mean follow-up period was 8.9 months (3-20). The mean interval between injections was 4.06 months. The mean Munk score improved from 3.92 to 1.78 (p<0.0001; paired two tailed t-test) suggesting a significant improvement. Transient ptosis was observed in 1 patient.
Conclusion:
LG BonTA gives acceptable resolution rates for epiphora/hyper-lacrimation among patients who do not prefer
Introduction:
Epiphora owing to lacrimal outflow obstruction affects a wide range of patients. It adversely affects their quality of life by causing blurred vision, irritation of the eye and periocular tissue and social embarrassment. Its standard treatment is surgical in the form of DCR (dacryocystorhinostomy) and even Jones tube intubation depending upon the location and extent of obstruction. Jones tubes, however, have a high rate of displacement and the need for further procedures and patient satisfaction does not always correlate with the anatomical success. Surgery may not be the best option in all patients especially in the elderly population. It may also be medically inadvisable in those who have undergone excision of lacrimal apparatus for treatment of malignant lesions affecting the neighboring anatomical structures. The main and accessory lacrimal glands both significantly contribute to basal and reflex tear production. Injection of botulinum toxin A (BoNTA) in the lacrimal gland blocks the presynaptic release of acetylcholine, which is required for tear secretion. BoNTA has been successfully used to treat excess tear production in the setting of gustatory hyper lacrimation owing to aberrant regeneration in proximal facial nerve injuries
Methods:
This was a retrospective interventional case series that included all patients who presented with excessive tearing. All patients underwent a thorough clinical evaluation that included irrigation and imaging studies where required. Only those who were not amenable to surgery to treat the epiphora / those who refused surgery / functional hypersecretion/ gustatory lacrimation were offered BonTA therapy. All those who agreed underwent transconjunctival injection under topical anesthesia. All patients were evaluated at 6 weeks. A previously validated Munk Score was used to assess all patients before and after therapy. The Munk’s score was as follows: 1. No epiphora 2. Occasional epiphora once or twice a day 3. Epiphora 2-4 times a day 4. Epiphora 5-10 times a day 5. Epiphora >10 times a day.
Results:
14 patients (17 eyes) were treated with injections of BonTA (2.5-5U) in the palpebral lobe of the LG. A mean of 2 injections (range: 1-3) were given per eye. The most common indication was canalicular obstructions (6/14;43%). The mean follow-up period was 8.9 months (3-20). The mean interval between injections was 4.06 months. The mean Munk score improved from 3.92 to 1.78 (p<0.0001; paired two tailed t-test) suggesting a significant improvement. Transient ptosis was observed in 1 patient.
Discussion:
Kaynak et al in a study to investigate and compare the efficacy of botulinum toxin-A injection in the lacrimal gland and conjunctivodacryocystorhinostomy surgery for the treatment of epiphora caused by proximal lacrimal system obstruction found that Conjunctivodacryocystorhinostomy requires surgical experience, special postoperative care, and multiple revisions. As botulinum toxin-A injection in the lacrimal gland is technically easy, less-invasive, safe, with reversible effects, it can be considered as an alternative treatment in patients with proximal lacrimal system obstruction. In their study, Improvement of epiphora was statistically significant at all visits when compared with values before injection (P<0.001) in both of groups. When two techniques were compared, difference in degree of epiphora before and after intervention was not statistically significant (P<0.05). In group 2, none of the patients had punctate epitheliopathy, although there was a significant decrease in Schirmer test results (P<0.001, paired t-test). In group 1, 9 cases (50%) had tube dislocation, 4 cases (22.2%) had obstruction, and granuloma formation. Five cases (25%) had ptosis in group 2.
Ziahosseini et al described their experience with the use of botulinum toxin (BoNTA) for the symptomatic treatment of lacrimal outflow obstruction. They retrospectively reviewed the case notes of patients with epiphora due to lacrimal outflow obstruction who chose to have injections of botulinum toxin into the palpebral lobe of the lacrimal gland instead of surgery between 2009 and 2014. Epiphora was graded subjectively with Munk scores obtained before and after treatment as well as qualitative degree of improvement reported by the patients. Severity and duration of side effects were also noted. In their study, Seventeen patients (22 eyes, mean age 70.3, 4 males and 13 females) were identified. A mean of 3.5 (range; 1-10) injections of BoNTA (Botox, Allergan; 1.25-7.5 units) were given per eye. The mean interval between injections was 3.9 months (range 3-6). The mean Munk score (3.4, range 2-4) improved significantly after treatment to 1.6 (range: 0-3, P=0.0001 paired two-tailed t-test). Epiphora completely resolved in a fifth, improved by up to 60-90% in a half and only ‘a little better’ in a further fifth. Temporary bruising and diplopia (lasting 2 weeks) was reported in 12% (2/17). They concluded that their outcomes for BoNTA to the palpebral lobe of the lacrimal gland in patients with lacrimal outflow obstruction epiphora seeking organisations considering the funding of this treatment.
This method has also been used in children. Eustis and Babiuch retrospectively evaluated the use of botulinum toxin injections to treat epiphora alternatives to surgery. This data provide further evidence for informed consent and for commissioning in children secondary to proximal obstruction of the nasolacrimal drainage system. Three patients (ages 8, 9, and 16 years) received botulinum toxin injections in the palpebral portion of the lacrimal gland. Two patients experienced symptomatic relief immediately following botulinum toxin injection. Both required subsequent injections, with an average symptomatic relief lasting 7 months. The only noted side effect was papillary conjunctivitis in one patient that resolved without treatment. The third patient was lost to follow-up. They concluded that although conjunctival dacryocystorhinostomy with Jones tube is the surgical procedure of choice for treating proximal lacrimal system obstruction, complication rates in children are high. Botulinum toxin injections provide a safe and effective alternative.
Conclusions:
Our study shows that LG BonTA gives acceptable rates of resolution and symptomatic relief from tearing among patients who are not good candidates for surgery or do not want surgery. However, ideal case selection is necessary to give good results. Further studies are required for standardization of doses and duration in between injections.
References:
- Kaynak P et al. Comparison of botulinum toxin-A injection in lacrimal gland and conjunctivodacryocystorhinostomy for treatment of epiphora due to proximal lacrimal system obstruction. Eye (Lond). 2016 Aug;30(8):1056-62.
- Falzon K et al. Transconjunctivalbotulinum toxin offers an effective, safe and repeatable method to treat gustatory lacrimation. Br J Ophthalmol. 2010 Mar;94(3):379-80.
- Ziahosseini K et al. Botulinum toxin injection for the treatment of epiphora in lacrimal outflow obstruction. Eye (Lond). 2015 May;29(5):656-61
- Eustis HS, Babiuch A. Botulinum toxin injection into the lacrimal gland for treatment of proximal nasolacrimal duct obstructions in children. J PediatrOphthalmol Strabismus. 2014 Dec 1;51 Online:e75-7.
- Wojno TH. Results of lacrimal gland botulinum toxin injection for epiphora in lacrimal obstruction and gustatory tearing. OphthalPlastReconstr Surg. 2011 Mar-Apr;27(2):119-21