Unilateral Blepharoptosis Combined With Malignant Exophthalmos After Botulinum Toxin Injection to Glabellar Lines: A Case Report.

[BACKGROUND] The ocular adverse reactions caused by the diffusion of BoNT-A injection are self-limiting, with symptoms ameliorating over time. Thyroid-associated ophthalmopathy (TAO) is an autoimmune disease characterized by symptoms such as exophthalmos, diplopia, and eyelid retraction, which may overlap the side effects of BoNT-A injections. It is crucial to consider other ocular diseases when assessing side effects after BoNT-A injection, particularly in patients with a history of thyroid disease.

[AIMS] To describe a complicated case of concurrent malignant exophthalmos and unilateral blepharoptosis following an additional dosage of BoNT-A injection for glabellar wrinkles.

[PATIENT] A 58-year-old female patient received BoNT-A injection for glabellar wrinkles. Two weeks later, the patient requested an additional dose of BoNT-A to enhance the effects, receiving an extra 8 units BoNT-A in the brow muscles. Twenty days later, she presented with a ptosis in the left eye, which progressively manifested into symptoms of exophthalmos, uncoordinated movement, blurred vision, and double vision. Ultimately, she was diagnosed with malignant exophthalmos.

[RESULTS] The blepharoptosis following BoNT-A injection typically manifests a significant improvement within 1-3 months. However, if the symptoms of ptosis persist without evident amelioration and are accompanied by additional ocular discomfort, particularly in patients with thyroid disease, the potential presence of concomitant TAO should be considered.

[CONCLUSIONS] This report highlights the potential relationship between botulinum toxin and thyroid disease, emphasizing the complexity of complications following cosmetic injections. Clinicians should carefully take the history of a patient, thereby facilitating better identification and management of potential complications.