Management of Severe Botulinum-Induced Eyelid Ptosis With Pretarsal Botulinum Toxin and Oxymetazoline Hydrochloride 0.1%

Background: Eyelid ptosis following periocular onabotulinumtoxinA (BoNT-A) treatment is a known complication that can be frustrating for both patients and practitioners. Iatrogenic blepharoptosis occurs due to local spread of the BoNT-A from the periocular region into the levator palpebrae superioris muscle. Although injectors should have a thorough understanding of the relevant anatomy in order to prevent it, BoNT-A induced ptosis can occur even in the most experienced hands. Objectives: The aim of this study was to describe a case series of patients treated effectively with topical oxymetazoline HCl 0.1% and pretarsal BoNT-A injections in the setting of botox-induced ptosis. Methods: The study group consisted of 8 patients who had undergone recent cosmetic BoNT-A treatment preceding the sudden onset of unilateral upper eyelid ptosis. Results: A diagnosis of severe ptosis (>3 mm) was made in all the cases in this series. Pretarsal BoNT-A injections alone or in association with topical administration of Upneeq eyedrops (Upneeq, Osmotica Pharmaceuticals, Marietta, GA) significantly reversed the ptosis in all treated cases. Conclusions: This is the first documented case series of patients treated effectively with topical oxymetazoline HCl 0.1% and pretarsal BoNT-A injections in the setting of botox-induced ptosis. This treatment combination is a safe and effective option in these cases.