Botox Therapy: Treatment Around the Eye

Periocular Treatment Around the Eye

This involves treatment of undesirable eyelid position and Crow’s feet wrinkles. Eyelid position should be evaluated.

Ideal eyelid position

The normal upper eyelid covers 1-2 mm of the iris of the eye, while the lower lid sits at the lower margin of the iris. The white of the eye therefore should not be visible at the north or south border of the iris of the eye. The distance between the upper and lower eyelid margins should be about 8-11 mm. The lower lid normally is 2 mm higher at the outside end compared to the inside end. Lower lid tone can be evaluated using the snap test. The lower lid is pulled down then allowed to snap back. A slow return to position is abnormal. This means special care is needed treating below the eye. The orbicularis oculi muscle surrounds the eye. It forces the eyelids closed. It is divided into 3 circular bands. If one band is paralyzed by Botox and another contracts the eyelid and lashes can be turned into the eyeball. The orbicularis oculi muscle should be felt to assess its size and shape. The dose and spread of Botox depends on these findings.

The levator palpebrae superioris muscle is in the upper eyelid and raises it. The second muscle in the upper lid is Muller’s muscle. It is not affected by Botox so if the levator palpebrae is paralyzed by Botox and the lid droops, apraclonidine drops can be used to stimulate Muller’s muscle and raise the lid.

Cross section of the upper eyelid

Crow’s Feet
Lines fanning out from the outside corners of the eye are called Crow’s feet. They become more evident when the orbicularis oculi muscle contracts. Crow’s feet worsen with sun damage to the skin, loss of fat, smoking, and prolonged squinting seen in fisherman, and lifeguards. Sometimes the wrinkling is caused by the cheek muscles pushing the skin up towards the eye. This is hard to treat and risks deforming the smile.

Before and after treatment of Crow’s feet with Botox

Injection sites for the treatment of Crow’s feet

Best case for Botox is mild to moderate wrinkles, or treatment of the “jelly roll” that protrudes under the eye when smiling. Botox should be used cautiously in patients with dry eyes, especially associated with Sjogren’s syndrome or rheumatoid arthritis, and also with eyes that don’t close well.

Patient Evalulation
A medical and surgical history should be done including prior plastic surgery, filler injections, or Botox use. An eye history should include tearing, dry eyes, and previous LASIK surgery which causes a higher incidence of dry eyes. Botox may worsen eyelid function and worsen dry eyes. Graves disease, Hashimotos thyroiditis, and collagen vascular diseases can affect the eyes as well.

The facial features are assessed. The resting wrinkles, eyebrow and eyelid position, and forehead wrinkles are checked. Forehead wrinkles may mean the patient is using the frontalis muscle to lift the drooping brow to see and thus treatment of the frontalis muscle may need to be avoided. If too much white of the eye is showing above and below the iris of the eye then further evaluation from an eye specialist is needed. Hidden brow sagging can be checked for. Tell the patient to relax the forehead. If the brow droops, Botox may not be used on the forehead. The patient should then close the eyes to make sure the lids do close. Then they should be forced closed to check for bulging of parts of the orbicularis oculi muscle that can be treated. Crow’s feet should be assessed from the front and sides.

Treatment Goals
Botox may treat Crow’s feet, elevate the brow, or treat the bulging part of the orbicularis oculi muscle in the lower lid. Only lines caused by the orbicularis oculi muscle should be treated. Going too low toward the cheek muscles will cause a disfigured smile. A tendency to under treatment may be safest. Patients can return in 2 weeks for touch up injections. Botox can be used to treat the jelly roll under the lower eyelid from a bulky portion of the orbicularis oculi muscle. However, if this is from excess eyelid skin, or skin pushed up by the cheek muscles, Botox will not help. Therefore a careful exam needs to be done.

If anesthesia is used, ice can be applied immediately before injection or anesthetic ointments can be applied. Usually 2-3 injections are done outside of the lateral corner of the eye, using 4-7 units/site, 12-20 units/side. Injection sites are marked with the person smiling maximally. The first shot is placed to the center of the area of the most wrinkling, 1-2 cm outside of the corner of the eye. The next 2 injections are 1-1.5 cm above and below the first. Injections should be done with the subject not smiling to keep Botox out of the cheek muscles. The effects should last about 4 months.

Complications
Injections may cause pain and bruising. Anesthesia with ice, anesthetic creams, and cold air chillers can help to avoid the bruising. Injections at the outside corner of the eye should be into the skin or fat and no deeper, not into the muscle. Brow and eyelid drooping has been described. A normal brow but only eyelid sagging may respond to apraclonidine eye drops, 3 times a day usually for 2-4 weeks. Other abnormal eyelid position can result in too much eye white showing or the lid border and lashes may curl into the eyeball. Tearing or dry eye from Botox getting into the lacrimal gland can occur. Needle injury to the eye or muscles that move the eye are rare.