The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face
Noah Scheinfeld MD
Dermatology Online Journal 11 (1): 9

Department of Dermatology, St Luke's Roosevelt Hospital, New York.

Abstract

A side effect of the injection of botulinum toxin into the upper third of the face is ptosis or lid droop. A therapy recommended to treat ptosis resulting from administration of botulinum toxins A and B is Iopidine™ (apraclonidine 0.5 %) eye drops. Apraclonidine is an α2-adrenergic agonist, which causes Müller muscles to contract quickly elevating the upper eyelid 1-3 mm. Little published data discusses the use of apraclonidine to treat such ptosis. This communication discusses the extant literature on this usage. Research needs to be done to establish the utility and dosing of apraclonidine for botulinum toxin-induced ptosis.



Communication

A side effect of the injection of botulinum toxin into the upper third of the face is ptosis, or lid droop. The incidence of ptosis after such injections is reported to be about 5 percent, and it can happen up to 2 weeks after injections. Ptosis results from migration of the botulinum toxin to the levator palpebrae superioris muscle. The levator allows the eyelid to open properly and fully. To avoid ptosis, injections should occur at least 1 cm above the eyebrow and should not cross the midpupillary line.

A therapy recommended to treat ptosis from administration of botulinum toxins A and B is the use of Iopidine™ (apraclonidine 0.5 %) eye drops [1]. Apraclonidine is an α2-adrenergic agonist, which causes Müller muscles to contract, quickly elevating the upper eyelid 1-3 mm. Apraclonidine is used to treat glaucoma and Horner syndrome because of its effects to increase muscle tone and decrease intraocular pressure. Apraclonidine has been reported to cause contact dermatitis [2, 3].

Despite the apparent widespread recommendations for the use of apraclonidine to treat botox-induced lid lag, we were unable to locate any literature that has formally evaluated its use. One possible reason of the paucity of reports on this subject is the reluctance of physicians to report iatrogenic side effects. The Emedicine online medical encyclopedia sections on dermatology [4], plastic surgery [5], and otolaryngology [6] recommend apraclonidine's use for ptosis, as does the web site of the New Zealand Dermatological Society [7]. Apraclonidine's use is mentioned briefly by Klein [8], who cites a presentation by Burns on the side effects of botulinum toxin [9]. A posting regarding iopidine use on the RxDerm-L online dermatology discussions elicited four responses from three dermatologists who used iopidine [10].

The most common dosing scheme used for iopidine is one or two drops three times daily until ptosis resolves. It is applied to the effected eye only. Some dermatologists recommend keeping in the office to use in case of ptosis and to obtain pre-administration images of the patient [10].

Other possible agents useful for the treatment of ptosis include brimonidine (0.1 % or 0.2 %) and neosynephrine hydrochloride (2.5 %). These agents also increase muscle tone, thus causing the eye to open more fully. Neosynephrine is contraindicated in patients with narrow-angle glaucoma and in patients with aneurysms. The risk of developing an allergic reaction to brimonidine in patients known to be allergic to apraclonidine is 22.7 percent, making it an alternative in allergic patients [11].

In conclusion, research needs to be done to assess the role of apraclonidine in treating the ptosis that can result from botulinum toxin injections into the upper face. Its optimal dosing needs to be established and the number of physicians using it needs to be established to understand fully its role in enhancing patient health.

References

1 Sadick NS. Botulinum toxin type B (Myobloc) for glabellar wrinkles: a prospective open-label response study. Dermatol Surg. In press.

2 Silvestre JF, Carnero L, Ramon R, Albares MP, Botella R. Allergic contact dermatitis from apraclonidine in eyedrops. Contact Dermatitis. 2001;45:251.

3 Armisen M, Vidal C, Quintans R, Suarez A, Castroviejo M. Allergic contact dermatitis from apraclonidine. Contact Dermatitis. 1998;39:193.

4 Trizna Z. Botulinum Toxin http://www.emedicine.com/derm/topic779.htm (accessed March 10, 2004).

5 Hauser RA, Wahba M. Botox Injections www.emedicine.com/plastic/topic509.htm (accessed March 10, 2004).

6 Molhotra PS, Danahey DG. Botox Injections for Hyperfunctional Facial Lines www.emedicine.com/ent/topic134.htm (accessed March 10, 2004).

7 Botulinum toxin. www.dermnetnz.org/dna.cosderm/botox.html (accessed March 10, 2004).

8 Klein AW. Complications, adverse reactions, and insights with the use of botulinum toxin. Dermatol Surg. 2003 May;29(5):549-56; discussion 556.

9 Burns RL. Complications of Botulinum Exotoxin. Portland, OR: 25th Annual Clinical and Scientific Meeting of the ASDS, May 1998.

10 RXDERM-L digest 2995-2998 March 8-9, 2004. Treatment of skin disease pass discussion. rxderm-l@ucdavis.edu.

11 Williams GC, Orengo-Nania S, Gross RL. Incidence of brimonidine allergy in patients previously allergic to apraclonidine. J Glaucoma. 2000;9:235-8.

© 2005 Dermatology Online Journal

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Title:

The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face

Journal Issue:

Dermatology Online Journal, 11(1)

Author:

Scheinfeld, Noah

Publication Date:

2005

Publication Info:

Dermatology Online Journal, UC Davis

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