Atropine Eye Drops Inappropriately Used for Diplopia Following Cosmetic Botulinum A Toxin Injections

Abstract

This is a first case report of atropine eye drops used inappropriately to treat diplopia that followed botulinum A toxin injections for a cosmetic indication. Also presented is a review of precautions on use of atropine eye drops by non-ophthalmic physicians.

Introduction

Botulinum A toxin (onabotulinumtoxinA) injection is the most common cosmetic procedure performed on U.S. adults.¹ Botulinum A toxin has an expanding number of promising therapeutic applications, especially migraine management.² Atropine eye drops, usually 1% or 0.5%, (Figure 1) is a potent drug used since the 1800s, mostly by ophthalmologists, for ocular diagnosis and therapy. Recent uses include dilute 0.01% atropine for slowing myopia progression.³

Figure 1.

Atropine eye drops have a red top and can keep a pupil dilated for over a month.

Source: Alcon

This is a first case report of atropine eye drops used inappropriately to treat diplopia that followed botulinum A toxin injections for a cosmetic indication. Also presented is a review of precautions on use of atropine eye drops by non-ophthalmic physicians.

Case Report

In June 2019, a 46-year-old self-referred female consulted the author for complaints of recent double vision, inability to read and fixed dilated pupils. She stated she had received bilateral botulinum A toxin injections for mild radiating aging skin lines at the lateral canthus (‘crow’s feet’). The spa-type clinic where she was treated is physician-directed but she was injected by a nurse. The physicians there are not ophthalmologists, ENT, dermatologists, or plastic surgeons, specialties usually trained in these types of injections. Four to five days after the first set of injections, she noted double vision. The diplopia was worse at distance than at near; worse in lateral gaze. She returned to the treating clinic. After telling them of her diplopia and having an examination, atropine eye drops were instilled in both eyes. The purpose of the drops was not explained to her. Within an hour after receiving the drops she noted her pupils were nonreactive, large and she could not read. At this point she made an urgent same day appointment with the author.

On examination her corrected distance vision was 20/20 with glasses, but her near vision was 20/80 near equivalent. Abnormal findings included underaction of both lateral recti, no ptosis, nonreactive 5 millimeter pupils in both eyes. The remainder of the eye examination was normal. During the exam, phone calls were placed to the treating clinic. The author’s staff was told that a physician there had directed atropine eye drops be instilled in both eyes after the patient returned with complaints of diplopia. With this additional confirmatory history, diagnoses of botulinum A toxin injection caused paresis of both lateral recti and subsequent iatrogenic mydriasis and paralysis of accommodation due to inappropriate atropine eye drop instillation were made. The patient was told that the double vision might take several months to clear. The dilated pupil and trouble reading might require weeks to over a month to wear off. The patient was given a time limited work excuse and warned about driving. She was told to return if her symptoms did not clear in the time outlined or other complications developed.

Subsequent calls were made by the author to the treating clinic office manager and the clinic’s physician medical director. Both refused to identify the physician ordering the atropine eye drops, or the reason for their installation or even why atropine eye drops were kept in their office. The patient’s double vision and dilated pupil gradually cleared over the following two months and she made a complete recovery.

Discussion

Since the days of ancient Greece and Rome it has been known that plants containing atropine (Atropa belladonna ‘deadly nightshade,’ jimson weed, mandrake) were toxic poisons⁴ (Figure 2). Pure atropine was synthesized in the 1830s. Once widely available, atropine caused a large number of deaths by accident, suicide, and homicide.⁵ Publication of iatrogenic morbidity or mortality from instillation of atropine eye drops were reported in medical journals as early as 1903⁶ and continue to the present day.⁷

Figure 2.

Attractive but deadly! Atropa belladonna extracts have been used for deadly poisons, medications, and highly diluted to cosmetically enlarge the pupil.

Source: Wikipedia

Atropine is an anti-cholinergic drug and, in eye drop form, a powerful, long acting pupil dilator (mydriatic) and paralyses the ability of the ciliary body to focus (cycloplegic) (Figure 3). Atropine eye drop effects may last several weeks in a dark brown iris and over a month in a light-colored blue iris. There are no eye drops, including pupil constrictors (miotic), that neutralize atropine in the eye. Intravenous physostigmine is used to reverse systemic overdose, usually from atropine taken by mouth to reduce oral secretions or by accident or intention.⁸ Eye drops that dilate the pupil by convention have bottles with red caps to help prevent accidental installation.

Figure 3.

In eyes with narrow angles atropine can cause acute angle closure and loss of eye. Physicians should consult an ophthalmologist before using or prescribing atropine or other mydriatics to the eye.

Source: Wikipedia.com by Nutschig

Atropine eye drops are not normally stocked in non-ophthalmic physicians’ offices. In the author’s ophthalmology office, atropine is kept apart from other short acting mydriatics and black tape applied to the red lid. Installation of atropine eye drops should ideally only be done after an ophthalmologist has examined the eyes to determine an indication for use and/or identify a contraindication. Atropine eye drops can cause potentially blinding acute angle closure glaucoma especially in hyperopes and Asians. A biomicroscope examination, plus in some cases gonioscopy, is needed to determine if the cornea-iris filtration angle is occludable.

Diplopia due to lateral rectus palsy from botulinum A toxin injection was first described in 2007 in a patient with facial spasms. ⁹ She recovered completely a month after injection. Diplopia due to botulinum toxin injection of the lower lids causing inferior oblique palsy has also been reported.¹⁰ Ptosis of the upper eyelids following botulinum toxin injection is reported and sometimes improved by the use of apraclonidine eyedrops.¹¹ Neither apraclonidine or any other eye drops have been reported to be useful for botulinum A toxin caused diplopia. Ocular muscle paresis or eyelid ptosis can be due to improper injection technique, excessive volume of injectant, unusual anatomy or idiosyncratic hypersensitivity to injectant. The incidence of these complications decreases with increased skill and experience of the person doing the botulinum A toxin injections. Given the frequency of botulinum A toxin injections, diplopia is an uncommonly observed complication of cosmetic treatment.

The use of atropine eye drops for treating double vision caused by lateral rectus palsy subsequent to botulinum A toxin injections as described in this case report is inappropriate and puzzling. There are no physiological mechanisms or scientific literature to support atropine use. Perhaps the physicians treating this case confused atropine with apraclonidine and the appropriate indication of ptosis with the inappropriate indication of diplopia.⁶ The treating physicians refused to discuss their rationale so this remains speculative.

Conclusion

Atropine eye drops have no role in the treatment of botulinum A toxin complications. Physicians considering using atropine eye drops to the eye should seek ophthalmological consultation before using or prescribing.