Development of a Protocol for Treatment of Crocodile Tears Syndrome with Botulinum Toxin

Purpose: To determine the incidence of crocodile tears syndrome in patients with long-lasting facial paralysis and establish a treatment protocol with botulinum toxin A (BTxA) applied into the lacrimal gland.

Methods: In a series of 372 patients with facial paralysis, 14 were diagnosed with the crocodile tears syndrome (CTS) by presenting hyperlachrymation while feeding themselves¹. Thirteen of them presented other synkinesis in the paralyzed side. They underwent a total of 31 BTxA applications to the lacrimal gland. Seven received a single percutaneous injection point, 13 received two percutaneous injection points and 11 received a single point into the lacrimal gland by direct vision (trans-conjunctival approach), after a slight eversion of the lateral portion of the upper eyelid with the patient looking inferonasally². The treatment success was assessed by the improvement of tearing reported by the patient: complete improvement of symptoms (grade 2), partial improvement (1), no improvement (0) and worsening of symptoms (-1).

Results: An average of 2.28 units-volume of BTxA (onabotulinumtoxinA 1U: 2.5U abobotulinumtoxinA per 0.02ml of solution³) was used. Trans-conjunctival approach presented a slightly better outcome, non-significant (55% complete improvement, 45% partial improvement) than percutaneous approach (45% complete improvement, 50% partial improvement). One patient in the percutaneous group had mild ptosis (spontaneous recovery after 15 days) and one patient had severe ptosis after trans-conjunctival approach. Only one patient (percutaneous approach) reported no improvement of tearing. The patients who underwent both techniques in different sessions (n=3) reported a better result after trans-conjunctival injection.

Conclusions: This study determined CTS prevalence after facial palsy (3.76%). Treatment should balance improvement of symptoms avoiding side effects. We propose a protocol beginning with 2U of BTxA in the lacrimal gland through trans-conjunctival approach. Complementary transcutaneous points can be added, according to the patients’ response.

References

1. McCoy FJ, Goodman RC. The crocodile tear syndrome. Plast Reconstr Surg 1979;63:58–62
2. Nava-Castañeda A, Tovilla-Canales JL, Boullosa V, Tovilla-y-Pomar JL, Monroy-Serrano MH, Tapia-Guerra V, Garfias Y. Duration of botulinum toxin effect in the treatment of crocodile tears. Ophthal Plast Reconstr Surg. 2006;22:453-6
3. Remigio F, Salles AG, Faria JC, Ferreira MC. Comparison of the efficacy of the 1:3 onabotulinumtoxinA: abobotulinumtoxinA ratio for the treatment of asymmetry after long-term facial paralysis. Plast Reconstr Surg. 2015;135: 239-49