Can the positions of the spastic upper limb in stroke survivors help muscle choice for botulinum toxin injections? / A posição do membro superior de indivíduos com doença cerebrovascular pode auxiliar na escolha de músculos para a injeção de toxina botulínica?

ABSTRACT Motor impairments in stroke survivors are prevalent and contribute to dependence in daily activities, pain and overall disability, which can further upper-limb disability. Treatment with botulinum toxin A (BoNT-A) is indicated for focal spasticity and requires knowledge of biomechanics and anatomy to best select muscles to be injected in the limb. Objective: We aimed to describe the frequency of posture patterns in a Brazilian sample of stroke survivors and correlate them with recommendations of muscle selection for treatment with BoNT-A. Methods: Fifty stroke patients with spastic upper limbs scheduled for neuromuscular block were photographed and physically examined, to be classified by three independent evaluators according to Hefter's classification. Muscles that were injected with BoNT-A by their routine doctors were retrieved from medical charts. Results: Pattern III and IV were the most common (64.7%, 21.6%). We further subclassified pattern III according to the rotation of the shoulder, which effectively interfered in muscle choice. The muscles most frequently treated were shoulder adductors and internal rotators, elbow flexors and extensors, in forearm, the pronator teres and finger and wrist flexors, and, in the hand the adductor pollicis. Conclusion: Frequencies of upper-limb postures differed from previous reports. Other clinical features, besides spasticity, interfered with muscle choice for BoNT-A injection, which only partially followed the recommendations in the literature.

RESUMO As deficiências motoras que ocorrem nos indivíduos com doença cerebrovascular (DCV) são prevalentes e contribuem para dependência, dor e incapacidade, o que pode atrasar a reabilitação do membro superior e sua funcionalidade. O tratamento com toxina botulínica do tipo A (BoNT-A) é indicado para a espasticidade focal e requer conhecimento da biomecánica e anatomia para melhor selecionar os músculos a serem injetados. Objetivo: Descrever a frequência de padrões posturais numa amostra de brasileiros com sequelas de DCV e correlacioná-los com as recomendações de seleção de músculos. Métodos: Cinquenta pacientes com comprometimento do membro superior devido a DCV do ambulatório de bloqueios neuromusculares foram fotografados e examinados para categorização de acordo com a Classificação de Hefter. Os músculos tratados pelos seus médicos de rotina foram obtidos a partir dos prontuários. Resultados: Os padrões III e IV de Hefter foram mais comuns (64,7%; 21,6%). Nós propusemos a subclassificação do padrão III de acordo com a rotação do ombro, pois isso interferiu na escolha dos músculos tratados. Os músculos tratados com maior frequência foram os adutores e rotadores internos do ombro; flexores e extensores do cotovelo; no antebraço, o pronador redondo, flexores dos dedos e do carpo e na mão, o adutor do polegar. Conclusão: As frequências das posições do membro superior diferiram de relatos prévios. Além da espasticidade, outros fatores interferiram na escolha dos músculos tratados, que seguiram parcialmente as recomendações da literatura.

Toxina botulínica para tratamento da sialorreia nos pacientes com doença de Parkinson / Botulinum toxin for treatment of sialorrhea in patients with Parkinson's disease

A sialorreia/ptialismo é um sintoma não motor frequente da doença de Parkinson, que pode causar impacto na saúde e na qualidade de vida dos pacientes. O sintoma decorre da combinação da disfagia com disautonomia e, muitas vezes, também do efeito adverso de drogas frequentemente utilizadas no tratamento de sintomas da doença, como por exemplo, os antipsicóticos atípicos e os inibidores da acetilcolinesterase. Diversas opções terapêuticas são utilizadas na prática clínica para controle da sialorreia, dentre elas, drogas anticolinérgicas ou antagonistas dos receptores adrenérgicos, injeção de toxina botulínica, cirurgia, radioterapia e terapias comportamentais e fonoaudiológicas. Este trabalho faz uma revisão das propostas terapêuticas até o presente momento para controlar a secreção de saliva dos pacientes com doença de Parkinson. A injeção de toxina botulínica nas glândulas salivares guiada por ultrassom é a opção com mais evidência de eficácia e segurança, de acordo com os últimos estudos.

Sialorrhea is a frequent nonmotor symptom in Parkinson´s disease (PD) that influences the patients' health and quality of life. The symptom arises from a combination of difficulty in swallowing saliva, autonomic dysfunction or as a side effect of frequent used drugs to control symptoms of the disease, as for example, atypical antipsychotics and acetylcholinesterase inhibitors. In clinical practice, different therapeutic approaches are used to control sialorrhea, such as anticholinergic or beta adrenergic antagonistic drugs, botulinum toxin injection, surgery, radiotherapy, behavioral psychotherapy and speech therapy. This paper reviews the therapeutic options available until now to control the loss of saliva from PD patient. Botulinum toxin injection in the salivary glands guided by ultrasound shows the best efficacy and security profile, according to the last published data.

Toxina botulínica: compuestos emergentes en Chile / Botulinum toxin: compounds emerging in Chile

Botulinum toxin A is a vastly used therapy for treatment or management of a variety of health conditions. We are talking about a biological compound which is nowadays manufactured by many different laboratories, with distinct and specific characteristics for each one of their products. Although research and use of this toxin have been worldwide established for many years , in Chile we have been using it for over twenty years and since then its uses have been expanding to many fields. During the last few years, new toxins from different laboratories have been incorporated to our country, being necessary to know about them, their similarities and differences as well as to be aware of the uses that are approved or not for each particular drug. (AU)

Perfil de dispensação da toxina botulínica para tratamento da espasticidade: dados nacionais brasileiros / Dispensing profile of botulinum toxin for treating spasticity: Brazilian national data

Os fisiatras especializados no tratamento de espasticidade foram reunidos para um painel de discussão a respeito do uso de toxina botulínica (TB) na rede pública de diferentes estados do Brasil. Os dados analisados durante a discussão do Datasus demonstram um baixo perfil de demanda desse produto dispensado pelo Sistema Único de Saúde (SUS), com uma heterogeneidade na distribuição da TB nos estados brasileiros. Esse quadro parece se configurar principalmente por falta de uma política pública devidamente planejada, como a falta de unificação e normatização dos centros de distribuição, pela falta ou inadequação da remuneração do procedimento de aplicação da TB aos centros de tratamento, de modo padronizado pela tabela SUS e escassez de médicos capacitados para realizá-lo junto à falta de centros de reabilitação multidisciplinar habilitados. O uso de toxina botulínica com finalidade terapêutica no Brasil teve início nos anos 90, para tratamento de distonia e de espasticidade. Atualmente, é empregada em diferentes condições clínicas, porém, apesar da crescente demanda e indicações ao longo dos anos, há poucos relatos ou publicações sobre seu uso e benefício para pacientes atendidos pela Sistema Único de Saúde (SUS). Para abordar esse tema, em maio de 2015, na cidade de São Paulo, fisiatras de diferentes estados do Brasil se encontraram e discutiram a relevância da toxina botulínica no tratamento de espasticidade

The physiatrists specialized in treating spasticity were brought together for a panel discussion about the use of botulinum toxin (BT) in the public system in different states of Brazil. The data analyzed during the discussion of Datasus demonstrate a low-demand profile of the product dispensed by the Unified Health System (SUS), with heterogeneity in the distribution of TB in the Brazilian states. This scenario seems to be set up mainly for lack of a properly planned public policy, such as lack of unification and standardization of distribution centers, the lack or inadequacy of TB compensation proceeding to treatment centers, in a standardized manner by SUS and shortage of trained doctors to do it together with the lack of qualified multidisciplinary rehabilitation centers. The use of botulinum toxin for therapeutic purposes in Brazil began in the 90s, to treat dystonia and spasticity. It is currently employed in different clinical conditions; however, despite growing demand and indications over the years, there are few reports or publications on its use and benefit to patients served by the Unified Health System (SUS). To address this issue, in May 2015, in São Paulo, physiatrists from different states of Brazil met and discussed the relevance of botulinum toxin in treating spasticity

The Pathogenesis and Management of Achalasia: Current Status and Future Directions

Achalasia is an esophageal motility disorder that is commonly misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia with solids and liquids but may focus on regurgitation as the primary symptom, leading to initial misdiagnosis. Diagnostic tests for achalasia include esophageal motility testing, esophagogastroduodenoscopy and barium swallow. These tests play a complimentary role in establishing the diagnosis of suspected achalasia. High-resolution manometry has now identified three subtypes of achalasia, with therapeutic implications. Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy. Close follow-up is paramount because many patients will have a recurrence of symptoms and require repeat treatment.

The long-term outcome of balloon dilation versus botulinum toxin injection in patients with primary achalasia

No abstract available.

Long-term outcomes of balloon dilation versus botulinum toxin injection in patients with primary achalasia

BACKGROUND/AIMS: We compared the long-term outcomes of balloon dilation versus botulinum toxin injection in Korean patients with primary achalasia and identified factors predicting remission. METHODS: We included 73 patients with achalasia newly diagnosed between January 1988 and January 2011. We ultimately enrolled 37 of 55 patients with primary achalasia through telephone interviews, who were observed for over 1 year. Short-term outcomes were evaluated from the medical records based on symptom relief after 1 month of treatment. Long-term outcomes were evaluated in a telephone interview using a questionnaire. RESULTS: Twenty-five patients were administered a botulinum toxin injection and 12 underwent balloon dilation. One month after the botulinum toxin injection, improvements were seen in chest pain (14 [56.0%] to 4 patients [16.0%]), regurgitation (16 [64.0%] to 4 [16.0%]), and dysphagia (25 [100.0%] to 5 [20.0%]). In the balloon dilation group, chest pain (8 [66.7%] to 1 [8.3%]), regurgitation (11 [91.7%] to 1 [8.3%]), and dysphagia (12 [100.0%] to 1 [8.3%]) had improved. A significant difference was observed in the mean remission duration between the botulinum toxin injection and balloon dilation groups (13 months [range, 1 to 70] vs. 29 months [range, 6 to 72], respectively; p = 0.036). Independent factors predicting long-term remission included treatment type (odds ratio [OR], 6.982; p = 0.036) and the difference in the lower esophageal sphincter pressure (OR, 7.198; p = 0.012). CONCLUSIONS: Balloon dilation may be more efficacious than botulinum toxin for providing long-term remission in Korean patients with achalasia. Follow-up manometry may predict the long-term outcome.

Combined treatment with botulinum toxin and hyaluronic acid to correct unsightly lateral-chin depression* / Tratamento combinado com toxina botulínica e ácido hialurônico para correção da depressão inestética lateral mentoniana

With aging, anatomical changes are observed in the face. In the lower third, these changes are expressed as ptosis of the angle of the mouth, lip enhancement groove mentalis; decrease in concavity between the jaw and neck and very noticeable platysmal banding. The repeated contraction of muscles of the lateral-chin together with the band platysmal side form what are called a marionette groove. Treating the whole lateral-chin area can result in a more harmonious aspect of the face when compared with treatment of a marionette groove in isolation. In this paper we describe combined treatment of the lateral chin area using botulinum toxin and fillers.

Com o envelhecimento observamos mudanças anatômicas na face. No terço inferior essas mudanças se expressam como ptose do ângulo da boca; acentuação do sulco lábio mentoniano; diminuição da concavidade entre a mandíbula e o pescoço e formação de bandas platismais bem evidentes. A contração repetida dos músculos da região latero-mentoniana juntamente com a banda platismal lateral, forma o que chamamos de sulco de marionette. Ao tratarmos toda região latero-mentoniana conseguimos um resultado mais harmônico, quando comparado com o tratamento isolado do sulco de marionette. Nesse artigo apresentamos o tratamento combinado da região latero mentoniana com o uso de toxina botulínica e preenchedores.

Upper face rejuvenation using botulinum toxin and hyaluronic acid fillers.

The demand for facial rejuvenation is increasing, with each passing day, in all age groups. A number of procedures like chemical peels, microdermabrasion, laser and light therapies, and minimally invasive procedures like botulinum toxin injections (BTX A) and hyaluronic acid (HA) fillers are being extensively used by the dermatologist and plastic surgeons to meet this growing demand. A good knowledge of use of these techniques is becoming imperative for the dermatologist. In the present article, we discuss in detail the use of botulinum toxin injections and hyaluronic acid fillers for rejuvenation of upper face. Special emphasis has been placed on the complications associated with treatment of each area and on how to manage the same.

literature review on the efficacy and safety of botulinum toxin: an injection in post-stroke spasticity

A variety of techniques for the management of spasticity have been suggested, including positioning, cryotherapy, splinting and casting, biofeedback, electrical stimulation, and medical management by pharmacological agents, Botulinum toxin A [BTA] is now the pharmacological treatment of choice in focal spasticity. BTA by blocking acetylcholine release at neuromuscular junctions accounts for its therapeutic action to relieve spasticity. A computerized search of Pub Med was carried out to find the latest result about efficacy of BTA in management of post stroke spasticity. Among 84 articles were found, frothy of them included in this review and divided to lower and upper extremity. BTA is a treatment choice in reducing tone and managing post stroke spasticity

Inhibir la contractilidad sin provocar necrosis: ¿sería útil en miocardiopatía hipertrófica? Modelo experimental de administración intramiocárdica de toxina botulínica y de wortmanina / Inhibiting contractility without necrosis: Would it be helpful for hypertrophic cardiomyopathy? Experimental model of intramyocardial botulinum toxin and wortmannin

En este artículo se presenta una idea original: inhibir la contracción miocárdica en forma regional y selectiva sin inducir necrosis. Se propone como una posible opción terapéutica en miocardiopatía hipertrófica asimétrica obstructiva, y se plantean 2 modelos farmacológicos basados en la administración intramiocárdica de toxina botulínica y de wortmanina.

The purpose of this paper is to introduce a new idea: local inhibition of contractility without necrosis. It's potential usefulness in hypertrophic cardiomyopathy treatment is discussed and 2 pharmacological models, administrating botulinum toxin and wortmannin directly in the myocardium are disclosed.

Tratamiento médico de la fisura anal con tadafilo tópico como principio activo / Medical treatment of chronic anal fissure with topical tadalafil

Introducción: La fisura anal es una úlcera lineal dolorosa que generalmente, aparece en la línea media posterior del canal anal, extendiéndose desde la línea dentada hasta el margen del ano. Su persistencia se debe al espasmo anómalo del músculo del esfínter interno. Hasta hace poco, la curación definitiva de las fisuras solo se logró mediante procedimientos quirúrgicos dirigidos a la ablación del espasmo esfinteriano. Diseño: Estudio prospectivo, controlado y aleatorio para comprobar la hipótesis de que la aplicación tópica de una preparación de Tadalafilo es un método efectivo y seguro para relajar el músculo liso y promover la cicatrización de la fisura anal. Población y métodos: Se seleccionaron los pacientes que acudieron a la consulta de coloproctología del HCC con diagnóstico de fisura anal (726). Todos fueron sometidos a una historia clínica y examen físico, antes del comienzo del tratamiento y seguimiento por 1 año. Los pacientes fueron divididos en tres grupos: Grupo A: tratados de forma médica con AINES por via oral, sediluvios y pomadas tópicas de esteroides 3 veces al dia. Grupo B: tratados con nitroglicerina 0,25% locales crema 3 veces al día. Grupo C: tratados con toxina botulínica inyectada 1 sola dosis en el espesor del esfínter interno del ano. Grupo D: tratados con formula magistral crema tópica de Tadalafilo aplicada 3 veces al día. Grupo E: pacientes a quienes se les realiza la Esfinterotomía Lateral Interna una vez que se considera ha fracasado el manejo médico y tratamiento farmacológico. Resultados: Se encontró predominio del sexo femenino con 370 pacientes (50.97%). Las edades en las cual se agrupó mayor cantidad de individuos fue entre los 26 a 35 años con 218 pacientes (30,02%). Predominó el diagnóstico de fisura crónica con 382 casos (52,61 %). El tratamiento inicial que se utilizó más frecuentemente fue el quirúrgico con 270 pacientes (37,19%), seguido de Tadalafilo tópico con 196 pacientes (26,99%)...

Introduction: Anal fissure is a painful linear ulcer usually appears in the posterior midline of the anal canal, extending from the dentate line to the margin of the anus. Its persistence is due to spasm abnormal internal sphincter muscle. Until recently, a definitive cure was achieved only cracks by surgical procedures aimed at ablation of the sphincter spasm. Design: Prospective. controlled trial to test the hypothesis that topical application of a preparation of Tadalafil is a safe and effective method to relax the smooth muscle and promote healing of anal fissure. Population and methods: We selected patients who attended the consultation of Coloproctology of HCC diagnosed with anal fissure (726). AIl underwent a medical history and physical examination before starting treatment and followed for 1 year. The patients were divided into three groups: Group A: treated medical oral NSAlDs, topical ointments sediluvios and steroids 3 times a day. Group B: treated with local nitroglycerin cream 0.25% 3 times a day. Group C: treated with botulinum toxin injection 1 dose in the thickness of the internal anal sphincter. Group D: treated with topical cream formulation TadalafiI masterfully applied 3 times a day. Group E: patients who underwent lateral internal sphincterotomy is considered after failed medical management and pharmacological treatment. Results: There was a predominance of females with 370 patientes (50.97%). The ages at which more individuals grouped was between 26 to 35 years with 218 patients (30.02%). The predominant diagnosis of chronic fissure with 382 cases (52.61%). The initial treatment was most frequently used surgical treatment of 270 patients (37.19%), followed by topical Tadalafil 196 patients (26.99%). The initial treatment had less failure was the use of topical Tadalafil 10 cases (1.37%), which required surgery...

Rejuvenecimiento no ablativo / Non ablative rejuvenation

La estética facial y el rejuvenecimiento se han desarrollado rápidamente debido a cambios en los productos, procedimientos y datos demográficos de los pacientes. Los clínicos pueden beneficiarse guiando en el uso de los productos, adaptando tratamientos a pacientes individuales, tratando múltiples áreas faciales, usando las combinaciones de productos para optimizar resultados. Cuando estas técnicas son combinadas, los resultados son superiores al empleo de terapias individuales. Las terapias posibles de combinar son: toxina botulínica, agentes de rellenos, peelings químicos, luz pulsada intensa láser ablativo y no ablativo. Recientemente, una variedad de sistemas de láser está disponible, que permiten un remodelamiento dérmico selectivo sin la disrupción de la superficie epidérmica. Más recientemente, el expertisse de los médicos con los sensibilizantes tópicos y las fuentes luminosas empleadas en la terapia fotodinámica ha conducido a mayores usos, incluyendo su empleo para la mejoría de los signos visibles del fotoenvejecimiento.

Facial aesthetics and rejuvenation are evolving rapidly due to changes in products, procedures and patients demographics. Clinicians can benefit from ongoing guidance on products, tailoring treatments to individual patients, treating multiple facial areas, using combinations of products to optimize outcomes. When these techniques are combined, the results are superior to the use of individual therapies alone. The possible combination therapies are: botulium toxin, fillers agents, chemicals peels, intense pulsed light, nonablative and ablative lasers. A variety of laser systems have recently become available that allow for selective dermal remodeling without disruption of the epidermal surface. More recently, increasing physician expertise with the topical sensitizers and light sources employed in photodynamic therapy has led to expanded applications, including its use for improvement of the visible signs of photoaging.

O uso da toxina botulínica na síndrome da bexiga hiperativa / The use of botulinum toxin in the treatment of overactive bladder syndrome

Nos últimos anos, a toxina botulínica (BTX) vem surgindo como uma opção para tratamento de algumas disfunções do trato urinário, como, por exemplo, a síndrome da bexiga hiperativa. Ela foi descrita pela primeira vez por Emile Pierre Marie van Ermengem em 1897 e desde então, vem se tornando uma importante arma terapêutica. Dos sete tipos distintos de BTX, somente os tipos A e B estão disponíveis para uso clínico. Seu mecanismo de ação consiste em causar paralisia flácida ao ser injetada no músculo, inibindo a ação da acetilcolina nas junções colinérgicas pré-sinápticas. Seu efeito é transitório e dose-dependente. A bexiga hiperativa é doença comum, que atinge cerca de 17% da população européia e norteamericana. Geralmente, ela é tratada de forma conservadora, principalmente com drogas antimuscarínicas, que são as drogas de escolha. Realizamos revisão da literatura, por meio do PubMed com o objetivo de verificar as indicações desta medicação, sua posologia, técnica de aplicação, efeitos colaterais, complicações e eficácia nas pacientes portadores de bexiga hiperativa neurogênica e idiopática. Foi concluído que a BTX parece ser uma opção de tratamento segura e eficaz para estas pacientes, porém mais estudos precisam ser realizados, principalmente para os portadores de bexiga hiperativa idiopática refratária aos tratamentos convencionais.

In the past few years, botulinum toxin (BTX) is being recognized as an option for the treatment of the urinary tract dysfunctions like overactive bladder syndrome. It was first isolated by Emile Pierre Marie van Ermengem in 1897 and, since then it is becoming an important treatment option. Of the seven distinct types of the toxin, only types A and B are available for clinical use. When injected into the muscle, the toxin acts by inhibiting acetylcholine release at the presynaptic cholinergic neuromuscular junction. Its effect is transient and dose-related. The overactive bladder is a commun disease that affects about 17% of the population in Europe and in the United States. Usually, the treatment is conservative and the mainstay is anticholinergic drugs. It was reviewed the literature using PubMed with the objective of verifying the indications, posology, technique of administration, side effects, complications and efficacy in patients with neurogenic and idiopathic overativity bladder. It was concluded that BTX seems to be a treatment option, which is safe and effective for these patients, but more studies are needed especially on the idiopathic overactive bladder.

Comparison of botulinium toxin injection and posterior anorectal myectomy in treatment of internal anal sphincter achalasia.

OBJECTIVE: We compared the efficacy of intra-sphincteric botulinum toxin (BT) injection and posterior anorectal myectomy (PARM) for the treatment of internal anal sphincter achalasia (IASA). METHODS: Twenty eight of 120 patients (23%) with chronic constipation, who were referred to our clinic from September 2005 to December 2006, were evaluated. Patients had an absence of rectoanal inhibitory reflex on anorectal manometry (ARM) and showed no transitional region on barium enema. Fourteen patients each underwent rectal biopsy, and were treated with either intrasphincteric BT injection (Group I) or PARM (Group II). Nine patients were excluded because of absent ganglion cells on histology or positive acetylcholinesterase staining (AChE). The remaining 19 patients were followed up. All patients underwent ARM and constipation severity score (CSS) assessment 2 weeks before, and 1 and 6 months after the treatment. Patients were followed up telephonically at 12 months after treatment. RESULTS: Clinically good response was seen after 12 months in 3 patients each in Groups I and II. The median values of resting rectal pressure in Group I before and 6 months after BT injection were 60 mmHg and 40 mmHg (p< 0.0001), respectively, while in Group II the corresponding values were 60 mmHg and 45 mmHg (p< 0.0001), respectively. Compared to pre-treatment, median CSS improved in both Group I (14 to 13) and Group II (16 to 14) at 6 months after treatment (p< 0.0001 for both). However, there was no difference in resting rectal pressure and CSS between the groups. Three patients in Group II developed local abscess, postoperatively. CONCLUSIONS: BT injection has a similar efficacy as compared with PARM for the treatment of IASA, is less invasive and, is also associated with fewer complications.

Fisura anal, opciones terapéuticas actuales: [revisión] / Anal fissure, actually treatment options: [review]

La fisura anal es una patología frecuente y probablemente la causante de la mayor parte de las proctalgias agudas severas. Esta revisión tiene por objetivo, evaluar los procedimientos actualmente utilizados para el tratamiento de esta enfermedad. En principio se describen algunos aspectos ligados a la etiopatogenia y a la evolución natural con la intención de comprender la utilización de las distintas modalidades terapéuticas. Posteriormente se analizan las características de cada método en particular, como así también sus beneficios, efectos adversos y resultados. Al final del trabajo, se expone el algoritmo de tratamiento seguido por los autores.

The anal fissure is a frequent pathology and probably the cause of most of the severe acute proctalgias. This revision has by objective, to evaluate the procedures at the moment used for the treatment of this disease. In principle some aspects related to etiopatogenia are described and to the natural evolution, with the intention to understand the use of different therapeutic modalities. Later the characteristics of each method in individual are analyzed, like thus also their benefits, adverse effects and results. At the end of the work, the algorithm of treatment followed by the authors is exposed.

Botulinum toxin injection in the treatment of upper eye lid retraction in thyroid ophthalmopathy

The aim of this study to evaluate the effects and safely of inducing a temporary partial ptosis of the eyelid through injection of botulinum toxin into the levator palpebrae superioris muscle. Eight cases with persistent lid traction with normal thyroid function and refused to be surgically corrected. Botulinum toxin a [BOTOX] was injected into the levator palpebrae superioris muscle after administration of topical anesthesia and the patient were followed up for one year. They were followed up with routine ophthalmic examination and measuring the degree of ptosis. All patients experienced relief of discomfort and appearance, ptosis induced in all cases to a variable degree. One week after the injection 2 patients [25%] experienced diplopia which was transient. All patients did not experience change in the degree of exophthalmos or tissue edema. BOTOX injection in the management of upper eyelid retraction is a safe technique simple and could be used in cases of contraindication of surgical intervention in cases of thyroid associated ophthalmopathy