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Speaker: Advise patients to stop anticoagulants before Botox injections
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NEW YORK — Some optometrists are now administering Botox treatments, and one preoperative instruction that is vital to good results is to cease the use of anticoagulants prior to the injection to reduce bruising, according to a speaker here at Vision Expo East 2012.
Botox (botulinum toxin, Allergan) is approved in the U.S. for a number of indications, including focal limb spasticity with strokes, hemifacial spasm, migraines, multiple sclerosis, myoclonic disorders, foot and hand hyperhidrosis, spasmodic dysophonia and myofacial pain associated with contraction.
The one approved indication for cosmetic use is for the glabellar area, Doug Devries, OD, said. "Other treatments, such as crow's feet, are off-label."
Contraindications for Botox use include pregnancy and lactation. Relative contraindications include disorders of the neuromuscular junction such as myasthenia gravis and Eaton-Lambert syndrome, disorders of muscle weakness and concomitant use of aminoglycoside antibiotics, he said.
Dr. Devries noted that optometrists in referral centers, working with MDs, are permitted to administer Botox injections, as are independent ODs in a few states such as North Carolina and Kentucky. He believes that in the future more states will allow independent administration of Botox by optometrists.
"The bottle of Botox looks like an old bottle that contact lenses use to come in, but empty," he said. "There are crystals in it that you reconstitute with saline."
The package insert says to dilute with 2.5 cc of saline, Dr. Devries said. "If you use less, it's more potent. If you use more, it's a weaker effect. But you still get the effect and you still get it in the same time. It just doesn't last as long," he said.
Dr. Devries explained that when you reconstitute the Botox, drip the saline slowly down the side of the bottle, then slowly spin it to mix. Do not shake it, he said. The U.S. Food and Drug Administration said the solution must be used within 4 hours, he noted.
Three areas of the face where Botox is typically injected are the glabellar area, the forehead and crow's feet, he said.
"When you first start doing this, you want to make sure you don't do more than two areas, maybe glabellar and crow's feet," Dr. Devries told the audience. "Just doing one area is recommended to start. There can be trauma from just one area. If someone wants all three areas, that's a lot of treatment and needle sticks in one day.
He said a 30-gauge needle is used, and the solution should be drawn up in smaller portions.
"A full syringe will be 40 units," Dr. Devries said. "I would draw up 20 ccs at a time. You never go back and hook that syringe back to the bottle again. If it doesn't get used, it's gone."
Patients should absolutely discontinue aspirin or ginkgo biloba, "any type of anti-coagulant, otherwise they'll be more susceptible to bruising," he said.
"Clean the area with an alcohol wipe and let it dry," he continued. "You can use an ice pack or cold pack, but most patients, once they have it done, say go ahead without.
"Take a skin marker and mark the areas to be injected," he continued. "Don't do it on the mark, do it next to the mark, otherwise you will tattoo them. It will push the ink right in."
The patient should contract his or her muscles so you can mark the injection sites. Determine how many units you will be using prior to the injection.
"That's where experience comes into play. Men have more muscle mass in their forehead and will need more," Dr. Devries said. "You want to come up with a plan on how many units and how you will divide it before you start."
Dr. Devries offered technical tips when performing Botox injections.
"Inject directly into the muscle; injecting superficially leads to more diffusion and lost toxin to the muscle," he said. "Better injection placement will mean better results and longer duration of action."
The treatment area for crow's feet is a "much more sensitive, painful area," he said. "Try to be sure you have a fresh, sharp needle."
Take before and after photos of the patient. "If the effect isn't as pronounced as the patient wants, don't give a refund," he said, "just do a little extra next time they come in."
Dr. Devries cautioned attendees about other available botulinum toxins, Dysport by Ipsen and Neurobloc/Myobloc by Elan. "They are absolutely not equivalent to Botox," he said.
Also beware of counterfeit Botox, which can cause paralysis.