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Ophthalmology-based treatments may have effect on seasonal affective disorder
Melissa Toyos, MD, FACS, explores how Botox and blepharoplasty could be used to treat seasonal depression.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
As we endure the cold winter months with short days and long nights, many patients develop depression, or seasonal affective disorder. This month, Melissa Toyos, MD, FACS, discusses two novel treatments for the ophthalmologist to help patients suffering from this disorder: blepharoplasty and Botox injections. We hope you enjoy this discussion.
Kenneth A. Beckman, MD, FACSOSN CEDARS/ASPENS Debates Editor
After the holidays come the winter blues, the post-holiday letdown. It is not hard to figure out why: The presents have been opened, the champagne popped, and now the bills are starting, the resolutions fading and we are faced with long stretches of time with few holidays or parties to break up the cold, short days of winter.
It is the time of year that seasonal affective disorder (SAD) can occur, leaving those affected depressed, fatigued and moody. Even though SAD can occur at any time of year, most who are affected by SAD suffer in winter, when days are short and nights are long. SAD is said to significantly affect up to 10 million Americans, with another 10% to 20% of Americans experiencing milder symptoms such as increased fatigue, cravings for sweet or starchy foods, decreased physical activity and difficulty concentrating.
There are a lot of theories about what causes SAD, but most of them center on how much natural sunlight a person receives. Symptoms increase during the winter months and the farther someone lives from the equator. Women seem to be at higher risk for the disorder as are those with a family history of depression. Researchers speculate that most of the symptoms can be traced to derangements of serotonin and circadian rhythms caused by the lack of sunlight.
Only a few treatments are available for those who suffer with SAD who are not able to easily move to the beach. Some people use special lights or wearable visors to mimic natural sunshine; others are prescribed anti-depression medications such as Paxil, Prozac or Zoloft. But there may be equally or more effective treatments already available in ophthalmologists’ offices to offer relief to these patients.
Dr. Norman Rosenthal is a South African psychiatrist and researcher who first coined the term “seasonal affective disorder” in the 1980s and has written more than 200 articles on it. In 2014, he published a paper showing that Botox (onabotulinumtoxinA, Allergan) is a safe and effective treatment of depression, including SAD. Injecting Botox into the corrugator and procerus reduces depression by disrupting emotional proprioception. The muscles of the face both reflect and influence mood, so it is true what your mother told you: If you do not make that angry face, you feel happier.
I came in contact with Dr. Rosenthal’s work when a friend asked if I would inject Botox for her father’s SAD. For him, seasonal affective disorder was debilitating and regularly consumed months of his life. He had tried every treatment, purchased a home in Florida for the worst of the winter months and still could not eradicate his symptoms. Injections of Botox, per Dr. Rosenthal’s protocol, ameliorated but did not eliminate his symptoms. After 2 years of injections, while doing a routine eye exam, I commented on his functionally significant dermatochalasis. He had no interest in the cosmetic outcome of the surgery but immediately noticed a significant increase in the amount of light as well as an increase in his field of vision when I physically lifted his lids.
The amount of light admitted into the brain through the eyes can be affected by pathologies of the eye, including dermatochalasis and cataract. There are many published studies that link cataract development and its removal to melatonin levels, sleep quality and circadian rhythms. The more light is blocked, the more patients seem to experience abnormalities in sleep and sleep patterns. The effect of blue-blocking artificial lenses on circadian rhythms has also been hotly debated. Cataract development and loss of visual field in glaucoma patients have historically been linked to depression.
If exposure to light reduces the symptoms of SAD, it stands to reason that letting more light into your eyes would only improve the symptoms. We are currently working with Dr. Rosenthal to study the effects of blepharoplasty on SAD. By the same token, I suspect that removal of visually significant cataract could influence the disease as well.
Many ophthalmologists already use Botox in their clinics for blepharospasm, migraine or cosmetic uses. Most of us offer cataract surgery and upper lid blepharoplasty. As ophthalmologists, we work to improve our patients’ sight every day. With techniques and tools already at our disposal, we may be able to enhance other parts of their lives, including their emotions, in ways that we might not have previously imagined.
- For more information:
- Melissa Toyos, MD, FACS, can be reached at Toyos Clinic, 2204 Crestmoor Road, Nashville, TN 37215; email: mtoyos@toyosclinic.com.
Disclosure: Toyos reports she is a speaker, consultant and does research for Shire; does research for Kala; is a consultant and does research for PRN Omega; and is a consultant for Magellan PRP. Her husband, Rolando Toyos, MD, invented IPL.