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To evaluate our experience of lacrimal gland botulinum toxin A (BoNTA) for treating epiphora.

Retrospective case note review of consecutive patients treated with lacrimal gland BoNTA injections over a four year period between Jan 2014 and Jan 2018.

Over the four year period fifty patients and 72 eyes (9 right, 19 left, 22 bilateral) underwent injection of botox to the lacrimal gland. Epiphora was associated with patent lacrimal ducts in 27 patients (54%) and these patient typically had unsuccessful initial surgery – 13 had prior DCR+/-tubes, 9 lid tightening (LTS) and 6 underwent punctoplasty (e.g. 3-snip). Other indications for treatment included gustatory hyperlacrimation (n= 6, 12%), canalicular obstruction (n= 8, 16%) and punctal stenosis (n=3, 6%). In those with canalicular obstruction 7 of 8 patients chose a trial of botox over surgical intervention.

The most common dose was 5 units (41 eyes) then 7.5units (19 eyes) and 10units (8 eyes). Less commonly 2.5 units (3 eyes) and 3.75units (one eye). Doses were titrated and augmented to patient reported response. Complications were limited to transient diplopia (n=7, 14%) and ptosis (13 patients, 26%). A total of 43 patients (86%) returned for repeat injection and 7 patients (14%) reported no benefit.

Epiphora leads to blurred vision, can affect quality of life and cause social embarrassment. Lacrimal gland botox provides an excellent alternative therapy with good results. In our experience, upward titration of the dose has greater patient reported success with the caveat of increased risk of complications.