Schirmer’s test scores were significantly lower in a larger proportion of those who received BoNTA injections, indicating these have the potential to affect basal tear production. Photo: Jessica Steen, OD. Click image to enlarge.

Dry eye encompasses a wide array of different causes and factors capable of exacerbating the condition. One that’s not as commonly discussed in the literature is Botox injections around the facial and specifically eyelid area.

Researchers wanted to carry out a wider scoping study than what literature currently exists on this phenomenon, seeing how Botox injections affect basal tear production as measured by Schirmer’s test scores with anesthesia in patients seeking eyelid surgery.

Included in the retrospective investigation was a total of 722 eyes of 361 patients who requested esthetic eyelid surgery, of which 670 eyes of 335 patients met the inclusion criteria; these cases were reviewed by a single clinician. Patients with no history of Botox injections were designated to group 1 and those with a positive, recent history of periocular Botox injections were designated to group 2. Compared between the groups were Schirmer’s test scores with anesthesia, measuring basal tear production. Score results of <5mm were graded as low, 5mm to 9mm was classified as borderline and ≥10mm was considered normal.

Mean age of participants was 55.1, ranging from 17 to 93, with 71.3% being female. In group 1, Schirmer’s scores were low in 32.9%, borderline in 26.4% and normal in 40.7%. In group 2, significantly lower overall results were observed, with low readings in 48.3%, borderline cases in 26.7% and normal scores in 25.0%. It should be noted, however, that no significant differences were seen between the two groups for ocular surface disease index symptom frequency scores or ocular lubricant requirements.

Generally, the authors of the study elucidate that those with a positive Botox injection history experienced lower basal tear production compared with those who never received any, making this a factor potentially risking subsequent dry eye.

The authors caution that “those performing eyelid surgery should be aware that patients who have undergone Botox treatment for lateral canthal rhytids and upper face rejuvenation may be more prone to decreased basal tear production as measured by Schirmer’s testing and subsequent risk of dry eye. This may not be symptomatic but should be identified before considering esthetic eyelid surgery, particularly as the risk of dry eye may be compounded by the choice of surgical approach.”

Better than just words of advice, they also include some tips: “Practioners should also be aware that certain aspects of the [Botox] technique can be modified to minimize dry eye complications and include the use of lower volume injections into target regions to minimize diffusion, as well as caution regarding injections into the lateral pretarsal orbicularis.”