What is Botox? | Botox For More than Just Wrinkles

Botox was first used by an ophthalmologist to correct double vision and facial spasms.  But today, Botox is best known for its ability to temporarily cure wrinkles and “crow’s feet.”

Back in the late 70s an ophthalmologist from California, Dr Scott, was looking for a way to help patients suffering from involuntary facial spasms and people with double vision. He figured out that with a purified version of botulinium toxin,  he could temporarily weaken or paralyze a muscle.  His first success was in treating patients suffering from double vision caused by the extraocular muscles which move the eye.

This discovery was just the first success story for Botox and has lead to further adoption in most of the fields of medicine.  Today, Botox is approved for various spastic disorders, headaches, over production of saliva…and all kinds of wrinkles.

The Botox discovery changed the lives of millions of people and has become one of the top used drugs of all time.

What is Botox?

Botox is a purified protein obtained from a bacteria called Clostridium botulinum.  This bacteria is responsible for causing the disease botulism. curacao .  The bacteria produces a protein called botulinum toxin.  We currently know “botulinum toxin” as simply “Botox.”

After Dr Scott sold the rights of this drug to Allergan, the pharmaceutical giant developed the many cosmetic uses for Botox.

Botox is simply injected directly into the affected muscle, the toxin then paralyzes the muscle for up to 3 months.  Side effects are few.

Botox and Lid Spasms

The original application for Botox was for certain cases of double vision.  Now, there are dozens of uses for Botox and here are a few related to ophthalmology.

Involuntary movement of a muscle is a spasm. When this occurs around the eye it is called a blepharospasm. This can appear as constant blinking when both eyes are involved or “winking” if only one side is affected.  Severe spasm of multiple groups of facial muscles can occur and cause an abnormal posture or grimace.  Bright light, dry eye, and even anxiety can make the spasms worse.

Blepharospasm can cause decreased vision, watery or dry eyes,  headaches and can even lead to social issues and depression. Most of the time the condition occurs from an unknown cause and tumors are only rarely seen. Before Botox,  the treatment was often systemic medications or disfiguring surgeries.  After the release of Botox the treatment of this disease underwent a dramatic change. Now with a few injections around the eyes the spams can be relieved for 3 months or more in most cases.

Botox at Sarasota Retina Institute

Neuro-ophthalmologist and oculoplastics surgeons commonly prescribe Botox.  We have some patients that have been getting this for almost 20 years in our practice and are still delighted with the results. It is a life changer. Insurance does cover this procedure which is a big relief to patients.

In the next article I will talk about the use of Botox for double vision and the relief of migraines.

If you or some one you know has spasms of the eyelids/face, double vision, or suffer from chronic migraines, call our office at 941-921-5335 and schedule an appointment to see if Botox could help you.

Tumors AROUND the Eye | Ocular Tumors

Last article gave some basic information about  tumors and what it means to be a malignant tumor. I would like to start talking about some of the tumors we see around and in the eye.

Tumors of the Eyelid

The outer most structures of the ocular system are the eyelids. The skin around the eye can develop tumors (benign or malignant) and so can the deeper tissue, some which can be potentially deadly.

I strongly recommend that any new lesion (aka lump or bump) on the eyelids be evaluated by a doctor trained and comfortable evaluating eyelid lesions.  Most oculoplastic eye specialists should be very comfortable evaluating tumors of the eyelids or surrounding structures.

Basal Cell Carcinomas

Basal cell carcinomas are one of the most common type of skin cancers. The tumor arises from uncontrolled growth of the bottom layer of the skin. They are commonly occur on the lower eyelids as the lower lids receive more sun exposure than our upper lids.  These types of cancers are often seen in patients over 50.

The lesions are often raised red areas, with enlarged blood vessels around or in it, and an ulcerated center. If it is growing at the edge of the lid near the lashes there is often a loss of the lashes (called madarosis). These lesions are usually slow growing and rarely metastasize to other areas.

Basal cells are usually very superficial, but there can be extension under normal skin. The basal cell cancers are removed with surgery and often examined pathologically at the same time to ensure the entire lesion is removed. Depending on the size of the lesion removed various reconstructive techniques are used to repair the remaining healthy lid tissue.

Squamous Cell Carcinomas

Squamous cell cancers arise from uncontrolled growth of the skins upper layer of skin (epidermis). These are less common then basal cell carcinomas. They are also induced by chronic exposure to sunlight. The incidence of both squamous and basal cell cancers can be reduced by wearing sunscreen, hats, and sunglasses. These tumors appears as scaly red patches that can bleed if scratched. These lesions can grow and spread to deeper structures. The lesions needs to be completely resected (removed) and then the area reconstructed. Incomplete excision can lead to the lesion spreading down nerves and can lead to extensive disease and possible death.

Sebaceous Cell Carcinoma

Sebaceous cell carcinoma is a lethal eyelid tumor that arises from the glands around the eye. While they are rare these tumors can be misdiagnosed for benign conditions such as chalazions (styes). They can often start as a yellowish nodules and progress to a chronically red looking lesions. There is often eyelash loss in the affected areas. The cancer is usually not painful. These tumors can spread throughout the orbital area and even to other parts of the body (a malignant tumor). The treatment for this tumor is surgical excision, which can be very disfiguring and possible chemotherapy. Even with this treatment the prognosis is often poor for long term survival. Early examination and diagnosis is essential.

Tumors of the eyelids are not uncommon, especially in the south like Florida. If you have a concerning “lump or bump” on your eyelid or around your eye, make sure you see an oculoplastic surgeon like Drs. Abrams, Spoor or Levy.

In the next article we will talk about tumors that involve the inside of the eye.


Tumors of the Eye | Ocular Tumors

As a neuro-ophthalmologist/oculoplastic specialist,  I treat patients with various tumors around their eye.

Tumors of the eye can occur on the eyelids, the eyeball itself, the tissue around the eye (the orbital area) or even the optic nerve.

Any tissue can develop a tumor.  Different types of tumors in various tissues often have characteristic behaviors.  These tendencies help us decide the appropriate treatment.  These articles are to help you understand some of the tumors that are seen around the eye.

Tumor and Cancer NOT Synonyms

Most people use the term tumor and cancer interchangeably but these do not mean the same thing. A tumor or neoplasm is an abnormal growth of tissue.  This can be any tissue in the body. Some tumors are benign and some are malignant.  The difference is based on the way the tissue act.

Benign tumors are tumors which do not spread, or metastasize, to other parts of the body.  Though a benign tumor does not spread, it can still cause damage.  For instance, large benign tumors of the optic nerve can cause loss of vision by compressing the nerve.

Depending upon the size, rate of growth and potential to blind, these tumors may be watched (i.e. left alone) or removed surgically.

Malignant Tumors

Malignant tumors can spread to other parts of the body.  There are different ways for the tumors to spread.  Parts of the tumor can spread through blood, lymphatic system, or directly invade surrounding tissue.  Often, malignant tumors are difficult to treat because they spread by multiple ways; not just one.

Treatment for malignant tumors can include surgery, chemotherapy and/or radiation.

Tumors Affecting the Eye

There can be either malignant or benign tumors around the eye. The tumor can be formed from local tissue (called a primary tumor) or have spread from other areas (called a metastasis). Sometimes in office examination , radiology imaging, or surgical biopsy with pathologic examination is needed to help determine the origin, type of tumor and then treatment course.

In our next article we will discuss some of the specific tumors we see around the eye and ways to diagnosis and or treat them.

The doctors here at Sarasota Retina Institute have special training dealing with tumors around the eye. Drs. Abrams, Spoor and Levy are part of a small group of surgeons in the country who work both on tumors of the eyelids and orbits. Using state of the  art techniques and equipment they are able to offer our patients care the rivals large academic centers around the country.

Eyes Squeezed Shut


Do you ever have a problem where your eyes want  to squeeze shut uncontrollably?   Do people accuse you or winking at them? Do you feel your lid twitching?

If you answered  yes to any of these you could be having blepharospasm.

What Are Blepharospasm

The eyelids have a muscle that goes around in a circle in both the upper and lower lids, called the orbicularis. This muscle is responsible for closing the eye. In patients with blepharospasm the muscle squeezes involuntarily.  This muscle over powers the muscle that opens the eyelid, the levator muscle, and causes the eye to shut.

 Causes of Blepharospasm

The spasms are caused by over stimulation of the muscle or the nerve that controls the muscle.  Sometimes this can be a tumor, trauma, dry eyes, or even an abnormality of a blood vessel. These are actually the rarer causes of blepharospasm. Most often there is no specific reason for the spasms, and this is called benign essential blepharospasm (BEB). This is a really fancy way of saying we do not know the true cause, yet it’s not due to a disease.

Treatment For Blepharospasm

30 years ago had you walked into your doctors office with blepharospasm the main treatment would have been sedating oral medications or surgery to remove the muscle, which was often very disfiguring. In the late 70s early 80s an ophthalmologist, Dr. Alan Scott, figured out that injecting botulinum toxin (Botox) into the muscle would temporally relieve the spasms.

Botox Preferred Treatment for Blepharospasm

And such Botox was created.  It was not until almost 12 years later that the use of Botox for cosmetcs was discovered.  Today injecting a botulium toxin (Botox/Xeomin/Myobloc)  for blepharospasm is still the preferred treatment.

 Botox Covered by Insurance

About 10 sticks per eye with a tiny needle is often all that is needed to reduce or eliminate the problem.   Treatment may be repeated in 3 months if needed. This is a medical problem and is paid for by most insurance plans.

If you or someone you know is suffering with blepharospasm call on of our neuro-ophthalmologsit at 941-921-5335 to get help.




Jody Abrams, MD, FACS
Sarasota Retina Institute
Sarasota, Florida 34239

The World Around The Eyeball

The Orbit

The orbit, or eye socket, is the cavity which holds the eye and its surrounding structures (such as muscles and fat) .  Except for the front, it is surrounded on all sides by bone.  The orbit is like an ice cream cone with the “ice cream” scoop facing front instead of “up.”  The ice cream scoop is the “eye.”  The bones on the side near the nose and underneath the eye are very thin, while the bone on the outside near the ear is the thickest. The bone at the top and the back of the orbit separate the orbital contents from the brain. The bones along the floor and wall near the nose are very thin and separate the orbit from the sinuses. Sinuses are areas in the skull that are filled with air. This keeps the head lighter and also better protects the face in the case of trauma.

Orbital Fractures

In fact, the bones of the orbit are thin so if the eyeball is struck, the thin bones will break prior to the eyeball itself breaking.  These orbital fractures can cause double vision, pain around the eye, or even no symptoms at all. Oculoplastic surgeons, such as Dr. Spoor or myself, specialize in fractures of the bones in the orbit. All breaks of the orbital bones do not have to be fixed, only when there are problems from the break.

Tumors Of The Orbit

Tumors can grow inside the orbit causing damage to the eye or its surrounding structures. The tumors can primarily grow inside the orbit, such as a cavernous hemangioma or can metastasize from other cancers in the body. The orbit is a tight space.  As tumors grow, softer tissues get compressed and the eye can get pushed out.  This can cause the eye to bulge out, decreased vision, pupil changes, and even long standing redness of the eye. When a mass is suspected an xray, CT scan or MRI is used to help find the mass. Sometimes the imaging can help make a diagnosis of the mass,  but other times surgery is needed to fully diagnose the lesion. There are multiple approaches used depending on the location. Sometimes the lesion can be removed entirely and sometimes a biopsy is taken and the lesion treated with medications.

The orbit is a incredible area that contains the eyes and its surrounding structures. It can suffer damage from trauma or even tumors. It is important to have any orbital problems addressed by oculoplastic specialists, doctors well versed and comfortable working in side and around the orbit. Dr. Abrams, Levy, and Spoor are orbital surgeons who commonly work in this small yet amazing area.  If you or someone you know have any questions, please leave a comment or give us a call at 941-921-5335.



Jody Abrams, MD, FACS
Sarasota Retina Institute
Sarasota, Florida 34239

Parkinson’s Disease and the Eye

What an incredible weekend. Saturday October 12 I had the honor of presenting at the Neuro Challenge Foundation conference on how Parkinson’s disease affects the eyes. I was amazed at the turn out, over 200 people. I presented a power point presentation (the one shown below) and then was able to answer audience questions.  What a wonderful conference. Dr. Sutherland and the entire staff of Neuro Challenge Foundation should be given a standing round of applause for the work they do.

I hope you enjoy the power point presentation.

If you or a loved one are affected by Parkinson’s disease and would like to learn more about it affects your eyes please call 941-921-5335 and schedule and appointment to speak with one our or doctors.

In the next few days I will send out what Drs. Levy, Torres and Rivero presented over the weekend.



Jody Abrams, MD, FACS
Sarasota Retina Institute
Sarasota, Florida 34239

Snoring May Blind You

Eyelid Problems with Sleep Apnea

When I was an Ophthalmology resident at LSU, I was taught about a certain eyelid condition, called Floppy Eyelids, associated with sleep apnea.

This is a condition where the lids become loose against the eyeball which in turn causes dry eyes, excessive tearing, foreign bodies (e.g. hairs and fibers), exposure of the surface and corneal scarring.

People with sleep apnea may rub their eyes a lot when trying to start breathing again and the chronic rubbing causes the tissue to become chronically stretched.  Over the years, I have been able to diagnosis sleep apnea on some patients by just examining their eyelids.  Once the sleep apnea is treated the eyelids can be fixed by an outpatient surgical procedure to tighten them.

Optic Nerve Problems and Sleep Apnea

When I finished training 7 years ago, sleep apnea was not associated with vision loss, but that has since changed.

A new emerging area for neuro-ophthalmology is damage to the optic nerve caused by sleep apnea.  I see many patients referred for problems of the optic nerve not explained by normal causes such as glaucoma.  Often the patient will have a “negative workup,” meaning tests like MRIs and blood tests are normal.

Until recently, there was no further workup, yet we’d have no idea about the cause of the vision loss.  Now I am sending many of our patients for sleep testing looking for evidence of sleep apnea.  I do this for all patients in whom I suspect sleep apnea and not just the typical overweight patients who have sleep apnea.    I diagnose optic nerve damage due to sleep apnea in all shapes and sizes and old and young.

Why Does Sleep Apnea Damage the Eye

In short, I’m not exactly sure how sleep apnea causes optic nerve damage, but there are some very convincing theories.

During sleep apnea the oxygen level in the blood decreases since the person is not breathing normally.  Perhaps this decreased oxygen level is damaging to the optic nerve, a tissue highly sensitive to variation in oxygen levels.

The optic nerve is a very active part of the body and such it needs a lot of oxygen. When the oxygen level decreases this causes stress and damage to the nerve which over time can cause vision loss.  Sleep apnea also causes changes in the blood vessels which can also decrease the oxygen delivered to the eye.

If the thought of high blood pressure, strokes and or heart attacks is not enough to get you checked for sleep apnea, then possible blindness might be.  To learn more about this call 941-921-5335 and make and appointment to talk with one of our doctors.



Jody Abrams, MD, FACS
Sarasota Retina Institute
Sarasota, Florida 34239

Get The Wrinkles Out Of My Headaches

I have had many headaches over my lifetime. The few times I had a true migraine made me understand how debilitating these can be. Once this problem gets going you are not able to really work through it. Take some meds, find a dark quite place, try to sleep and hope it is gone when you wake up. I am one of the lucky people who my true migraines only lasted a few years and I have not had one since.

I see patients all the time who are chronic migraine sufferers and continue to struggle with this problem. The migraines can cause them to have problems with work and even their family life. It is a hard disease for others around to deal with since the person is in so much pain without any obvious injury.

What is a Migraine?

A migraine is a severe headache. It can often be preceded by visual symptoms such as flashes of light. The patients will even sometime experience the sensation of a certain smell before their migraine starts. Often the headache quickly progress and can cause severe debilitation. ip information It can last a few hours to days or even longer. Migraines have even been known to cause symptoms resembling a stroke such a weakness in one side of the body.

What Causes a Migraine?

The causes of migraines is not fully understood. We know that environmental and genetics play a role, and it is often different for each person. Some common causes are:

  • Hormonal
  • Foods such as cheese, chocolate, and salt
  • Alcohol, especially wine
  • Physical activities

What are Treatments for Migraines?

For years migraines were treated with narcotics to dull the pain. More recently medications such as Maxalt and Relpax have been taken when a migraines start to help abort the headache. For years different medications have been used off label (without FDA approval) to try and stop migraines from starting. Three years ago the FDA approved the first medication for the prophylaxis of migraines, Botox.

The doctors at Sarasota Retina institute have been using Botox for many years to help migraine suffers. Even before the FDA approved it, we saw great results from the medication.

Botox has been a wonderful drug for our migraine patients. They have been able to reduce the number of headaches a month, and the severity of the headaches when they occur. It does not seem to matter the cause of the migraine, Botox helps in most chronic migraine suffers.

Next time I will talk more about who qualifies for Botox treatment of migraines, how it is done, and even the fact that it is covered by most insurance plans now.

If you suffer from chronic migraines and would like to learn more about the safe and effective treatment, call us at 941-921-5335.


Jody Abrams, MD

Oculoplastics and Neuro-ophthalmology

Sarasota Retina Institute 

Sarasota, Florida



The Ugly Looking Eye

Red eyes are ugly.  Red eyes can be benign or very dangerous.

There are lots of reasons why an eye may become red.  Often, “Visine” can work, but there are times when a “red eye” is very dangerous.


Eyes are usually beautiful to observe.  As an eye MD, even after 35 years of practice, I am enthralled at the beauty of most eyes that I examine.  It is also amazing how this thing of beauty can become so ugly so quickly.  Ugly eyes make most physicians, even experienced eye MDs cringe and look for a place to send the patient.  This is what makes our referral practice successful.

Blood Around The Eye

Hemorrhages under the conjunctiva (the mucous membrane surrounding the white of the eye) look terrible but are most always benign and resolve with or without our help.  Red eyes from superficial infections (conjunctivitis {pink eye}) also may look terrible but are usually self-limiting and also resolve with or without our help.  Although unlike the hemorrhages appropriate eye drops may lead to a much more rapid recovery.  Vision is usually normal in these ugly, red eyes.

Dangerous Causes Of Red Eye

Other causes of red, ugly eyes are much more sinister and usually are accompanied by decreased vision and pain. Inflammation or infection inside the eye or around the eye causes extreme pain and decreased vision.  This is always a warning sign to obtain help from an experienced eye MD.

Important Causes Of Red Eye

Inflammation must be differentiated from infection.  Most eye inflammations are very treatable with cortisone drops or pills.  Infections will be markedly worsened by cortisone treatment and this may result in permanent loss of vision, loss of the eye or even death.  Accurate diagnosis is obviously very important to make sure correct diagnosis is given.

If you have a red eye, call us to have it examined and make sure your vision is preserved. You can call 941-921-5335 for an appointment.


Tom Spoor, MD
Oculoplastics and Neuro-ophthalmology
Sarasota, Florida

Tom Spoor,MD
Oculoplastics and Neuro-ophthalmology
Warren, Michigan

Stop The Burn

Treating dry eye

I never thought I would be involved in treating patients with dry eye problems.  I am an oculoplastic surgeon and neuro-ophthalmologist.  Treating tearing ok, but dry eye symptoms belong to the cornea and external disease specialists. However these patients present to the neuro-ophthalmologist with undiagnosed complaints ranging from pain in the eyes to fluctuating or decreased vision.  These symptoms are very often undiagnosed and subsequently the patients suffer for a prolonged period of time when help should be readily available.

As I have mentioned in previous articles, the key to accurate diagnosis and treatment is the use of a vital stain (Lissamine green) at the beginning of the examination.  Vital stains (which lissamine is) stain devitalized tissue.  Dry eyes stain with speckled spots of  lissamine green stain.  If the conjunctiva stains you have moderate dry eye, if the conjunctiva and cornea stain you have severe dry eye.  It is really that simple.

Artificial Tears

Conventional wisdom and the party line is treat mild dry eye with some artificial tear preparation.  This sound good and cost effective but artificial tears are not real tears.  Your tears are composed of a very complex mixture of proteins, antibodies, enzymes and lubricants.  You can’t find these in a bottle of tears.  After a trial of tears most patients are not happy.  Tears are expensive and have to be dropped in the eyes many times during the day.  This is especially hard for seniors who may have some arthritis problems and difficulty using eye drops.

Alternative Options for Dry Eyes

Why not keep your own tears around longer?  This is easily accomplished by partially occluding the tear drainage system with a punctual plug.  These are tiny devices that are eventually dissolved by the body that delay the drainage of tears from around the eye.  This keeps the tears with all their valuable ingredients in contact with the eyes longer and very effectively and conveniently alleviates dry eye symptoms.  They can be placed in the office during the examination with little or no discomfort.   The effects can be amazing.

How Important is Dry Eye Treatment

Early in my dry eye career a patient was referred to me for an unrelated surgical procedure.  During her complete examination I noted significant lissamine green staining of her eye indicative of severe dry eye.  I placed plugs in all four of her drainage holes (puncta) and scheduled her for her unrelated surgery.  When I saw her in the pre-operative holding area she gave me a huge, tearful hug stating that she felt so much better and why could not the 6 previous ophthalmologists do what I had done for her.  This is the value of lissamine green and punctual occlusion.  This scenario plays s out in the office almost every day.  Dry eye is common and usually easily treatable with simple office procedures.

If these symptoms sound familiar to you please call 941-921-5335 to see one of our dry eye specialist.Tom Spoor, MD

Oculoplastics and Neuro-ophthalmology
Sarasota, Florida

Tom Spoor,MD
Oculoplastics and Neuro-ophthalmology
Warren, Michigan