The Ophthalmology Unit,  Universiti Malaysia Sarawak (UNIMAS), Kuching, Sarawak.

The Ophthalmology Department, Sarawak General Hospital, Kuching, Sarawak, East Malaysia.



Subconjunctival botox for thyroid eye disease

Photo by Professor Chua

A 41 year-old woman with controlled Graves' disease complained of a 2-year history of ocular irritation from eyelid retraction. The irritation was worse in the left eye than the right eye. Examination revealed bilateral exophthalmos (L>R) and upper eyelid retraction (L>R). The tear films are poor with puntate keratitis in both eyes (L>R). Despite hourly use of artificial tear, the ocular irritation remained. Her visual acuities, colour vision and intraocular pressures in both eyes were normal. Ocular movement showed bilateral restriction of upgaze. Orbital decompression was suggested but declined by the patient because of the possible risk of binocular diplopia. She was also not keen for levator recession to lower her eyelids. To give her temporary relief, she agreed to subconjunctival injection of botox lower the left upper eyelid. 


Bilateral exophthalmos and eyelid retraction.


Side view of the proptosis.


Subconjunctival injection of botox into the levator aponeurosis (20 units of Botox was given,the total volume was 0.2ml constituted by adding 1ml of 0.9% NaCl solution to 100units of Botox).


Left ptosis 48 hours after the injection. The right eyelid was later injected with

a similar dose of Botox.

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