Pop-ups show botulinum toxin injections as an effective therapeutic strategy for patients with various types of ocular surface disease (OSD). The findings suggest that this approach can improve anatomical abnormalities and symptoms in OSD, without interfering with other treatment regimens.1
First developed for clinical use by ophthalmologist Alan Scott, the US Food and Drug Administration (FDA) approved botulinum toxin in 1989 for the treatment of strabismus and blepharospasm associated with dystonia.1 The undisturbed appearance of patients with blepharospasm after botulism toxin treatment reportedly inspired later research exploring its cosmetic applications.3
Several decades later, botulinum toxin is still used for each of these purposes and many additional FDA-approved indications, as well as numerous off-label applications, with a generally favorable safety profile.4-6 Among other conditions related to eye care, botulinum toxin is used in the treatment of facial hemi-spasm, facial paralysis, spastic entropion, endocrine trochopathy, convergence spasm, and facial trauma.7
In a paper published in October 2025 in Journal of Visual ExperimentsKaleb Abbott, OD, MS, and colleagues described a protocol for delivering botulinum toxin injections for the treatment of ocular surface friction-associated disease (EAOSD).1 Dr. Abbott is an optometrist and assistant professor of ophthalmology at the University of Colorado School of Medicine in Aurora.
“Botulinum toxin … works by inhibiting the release of acetylcholine at the neuromuscular junction, leading to temporary muscle weakness,” as explained in their paper.1 “When carefully injected into the orbicularis oculi, frontal or tarsal plate, botulinum toxin can reduce muscle tension around the eyelids, which improves eyelid tone and the anatomical fit between the eyelid and ocular surface tissues.”
According to the article, some of the proven benefits of botulinum toxin injections into the eyelids or periorbita include reducing inflammation in dry eye, increasing meniscal height, reducing tear osmolality, improving signs and symptoms of blepharospasm, and improving tear retention.1
While upper eyelid ptosis is the most common complication associated with periorbital botulinum toxin injection, it occurs rarely and usually resolves over time. Other potential complications of periorbital botulism toxin injection “include entropion, ectropion, eyelid ptosis, eyebrow drooping, squint, and incomplete eyelashes, which may temporarily worsen ocular surface symptoms but generally resolve without permanent sequelae,” according to the study.1
However, with the technique described in the paper, these “complications are all extremely unlikely given the proposed injection site, and such effects can be largely mitigated by the use of conservative doses, small injection volumes, and precise injection technique.”1
Noting the accumulating evidence supporting this treatment strategy for EAOSD, the researchers provided case examples with photographs as well as detailed guidelines to guide clinicians in providing botulinum toxin therapy to patients with various types of EAOSD. Points covered include dosage, injection sites, patient selection and other details for each condition.1
In an interview with Consultant OptometryDr. Abbott discussed highlights from the article and the potential role of botulinum toxin in the treatment landscape for EAOSD.
To clarify, what is EAOSD and what role does friction play?
Dr. Abbott: EAOSD refers to a disease of the ocular surface that does not result from tear deficiency, but from problems related to the eyelids. Abnormal eyelid anatomy or eyelid mechanics can lead to excessive friction between the upper eyelid and the superior cornea, bulbar conjunctiva, or wiper area. This friction can cause irritation, superficial staining, mucous plaques, and persistent discomfort, even when tear quantity and quality are normal. Classic examples include superior limb keratoconjunctivitis (SLK), wiper epitheliopathy (LWE), tight eyelid syndrome, and orbital ophthalmopathy.
Your recent paper discusses botulism toxin injections for abrasion-related EAOSD. What were your main findings with the 3 cases described in the article?
Dr. Abbott: Botulinum toxin has a long history in eye care. In this application, we use it to selectively relax the orbicularis oculi muscle in the upper eyelid, reducing eyelid tension and changing eyelash dynamics. This softens the lid-globulin interaction and reduces friction during flashing. In our work, three patients with EAOSD showed reduced staining and symptomatic improvement after a single injection of 1 unit botulinum toxin – all without changes in their other treatments. Although preliminary, these results suggest that botulinum toxin may effectively address the anatomical component of EAOSD.
How botulinum toxin works comparison with other treatment options for EAOSD?
Dr. Abbott: Traditional dry eye treatments target tear production, stability, or inflammation, but do not change eyelid mechanics. Bandage contact lenses can reduce friction by providing a barrier and newer agents such as Miebo® (perfluorohexyloctane ophthalmic solution) show early promise in reducing surface friction.8,9 However, botulinum toxin is unique because it directly modifies eyelid anatomy and aperture mechanics, addressing the root mechanical cause rather than simply compensating for it.
For clinicians who are new to this topic, can you provide an overview of how botulinum toxin is made is the process running on EAOSD?
Dr. Abbott: The process is simple. We inject 1 unit of botulinum toxin into the upper eyelid in the area of greatest friction, determined by lissamine green or fluorescein staining of the superior cornea, superior bulbar conjunctiva, and wiper area. The injection gently relaxes the orbicularis oculi, reducing eyelid force and eyelid-ball interaction. Results usually begin within several days, with improvement in symptoms and pigmentation noted by the end of the first week. It’s a low-risk, targeted treatment that can be repeated every few months, as needed.
What else should clinicians know about this emerging treatment strategy for EAOSD?
Dr. Abbott: EAOSD patients are often misclassified as having traditional dry eye and struggle with persistent symptoms despite standard treatment. Botulinum toxin provides a new, anatomically based option for these patients – particularly those with SLK or wiper disease. While the data are early, the approach is practical, well tolerated, and fills an important gap in our current therapeutic paradigm.
It is likely to become an increasingly valuable tool in the management of complex ocular surface diseases.
