The vast majority of Botox and other neuromuscular injections for wrinkle reduction are used in the forehead. While there are some minor complications with these injections, such as bruising, low dose uncorrection and unusual forehead wrinkle patterns, the most severe problem is that of lid droop or ptosis. If injections are done too close to the eyebrows, the agent can diffuse down into the upper eyelids. This can result in inadvertent partial paralysis of the levator muscles of the upper eyelids which are responsible for eyelid opening.
While these untoward Botox effects are temporary, upper eyelid ptosis can be severely distressing to the one so affected. While this is a known risk of Botox injections into the forehead, this does make it any more pleasing to the patient. The incidence of this aesthetic complication is reported to be around 5%, although I have never seen it in my experience to be this high. Once it occurs, it can take 6 to 8 weeks to wear off in most cases. There are a handful of cases in which it can last much longer.
Once placed, there are no reversal methods for Botox, Dysport or Xeomin injections. Time is the only treatment in which these drugs will eventually wear off in a few months. As a palliative treatment, eye drop therapy can be useful for upper eyelid ptosis from these agents. One drug recommended is that of Iopidine. (apraclonidine 0.5%) This eye drop is commonly used to treat glaucoma. It can improve eyelid ptosis by causing Muller muscles to contract which can elevate the upper eyelid by several millimeters. This drug increases the muscle tone of this muscle causing it to contract. Because Mullers muscle lies just under the inner lining of the upper eyelid, the eye drop easily diffuses into it. It is given by one or two drops three times a day in the affected eye until the ptosis goes away.
Other eye drops options recommended have been brimonidine (0.1%) and neosynephrine (2.5%) These agents can also increase the tone of Muller’s muscle, causing the eyelid to elevate and open the eye more fully. Whether these are as effective as that of Iopidine, or maybe even more so, is not known nor has any comparative study ever been done.
Dr. Barry Eppley
Indianapolis, Indiana