To the Editor,
I am writing regarding the article in the May 2012 issue, “Speaker: Advise patients to stop anticoagulants before Botox injections” (page 6) as part of the Vision Expo East meeting coverage.
In the article, the presenter, Douglas Devries, OD, suggested that a full syringe of Botox (botulinum toxin, Allergan) would be 40 units. This certainly depends on the dilution and the size of the syringe.
The article also states that, “You never go back and hook that syringe back to the bottle again.” I am not sure what “hook” means in this context. The medication is labeled “single patient use,” and to avoid cross contamination this regulation should be strictly followed. This has become a major issue after an outbreak of hepatitis was linked to potential re-entry of vials of propofol in a gastrointestinal surgery center.
I typically use a 30 gauge to 31 gauge needle on a 1.0-cc insulin syringe. To minimize bruising, I do not discontinue anticoagulants, as these medications can have a life saving purpose (preventing stroke or myocardial infarction). The risk (death) vs. the potential cosmetic benefit (minimizing bruising) is not justified. When injecting, I look for visible vessels through the skin and avoid them. I also immediately apply pressure to the injection sites to tamponade any potential bleeding and minimize subsequent bruising.
The article suggested that the optometrist draw up 20 cc at a time. The diluent is important as well as the quantity. I believe a decimal point is missing (2.0 cc).
I have been injecting Botox for years, and the suggestions by Dr. Devries were insightful. I was not aware that optometrists “working with MDs, are permitted to administer Botox injections.” As I have optometrists working with me, I would like to learn more about this.
Southwest/Ohio Valley Eye Institute
Disclosure: Dr. Malitz has no relevant financial interests to disclose.
Dr. Devries responds:
Thank you for your letter. The article does require further clarification.
The recommended dilution of Botox (botulinum toxin, Allergan) cosmetic is 2.5 mL of sterile nonpreserved saline per 100 units of toxin. This would mean that a 1-cc syringe would be 40 units of Botox. Any reference in my lecture of dilution would be referring to the package insert recommended amount of 2.5 mL of sterile nonpreserved saline per 100 units of toxin.
All of our doctors in our clinic use 1-cc syringes as well, which means in order to draw the entire 100 units (2.5 mL), you would need to use at least three different syringes as opposed to drawing more Botox with the same syringe. (Thus avoiding cross contamination.)
I also agree with your comments regarding not discontinuing anticoagulant therapy. I was referring to supplements such as ginkgo biloba or omega 3s, which may have an anticoagulant side effect for a patient. Our clinic would never recommend discontinuing anticoagulant therapy for the sake of bruising. Your techniques described to minimize bruising are appropriate and I believe widely practiced.
A point of further clarification: all optometrists working with MDs are not necessarily permitted to inject Botox. These laws vary from state to state and, therefore, would need to be looked at on a state-by-state basis.