Dosing considerations1

  • BOTOX® is intended for injection into extraocular muscles utilizing the electrical activity recorded from the tip of the injection needle as a guide to placement within the target muscle
    • Injection without surgical exposure or electromyographic guidance should not be attempted
    • Physicians should be familiar with electromyographic technique
  • To prepare the eye for BOTOX® injection, it is recommended that several drops of a local anesthetic and an ocular decongestant be given several minutes prior to injection
  • The volume of BOTOX® injected for treatment of Strabismus should be between 0.05 and 0.15 mL per muscle
  • The initial listed doses of the reconstituted BOTOX® typically create paralysis of the injected muscles beginning 1 to 2 days after injection and increasing in intensity during the first week
    • The paralysis lasts for 2 to 6 weeks and gradually resolves over a similar time period
    • Overcorrections lasting over 6 months have been rare
  • About 50% of patients will require subsequent doses because of inadequate paralytic response of the muscle to the initial dose, or because of mechanical factors such as large deviations or restrictions, or because of the lack of binocular motor fusion to stabilize the alignment

BOTOX® recommended initial doses for Strabismus1


Vertical muscles

Horizontal Strabismus

< 20 prism diopters

20 to 50 prism diopters

Persistent VI nerve palsy ≥ 1 month

Maximum recommended dose for a single injection


1.25 to 2.5 Units


1.25 to 2.5 Units

2.5 to 5 Units

1.25 to 2.5 Units (in medial rectus muscle)

25 Units

Use the lower listed doses for treatment of small deviations. Use the larger doses only for large deviations.

Subsequent doses for residual or recurrent Strabismus1

  • It is recommended that patients be re-examined 7 to 14 days after each injection to assess the effect of that dose
  • Patients experiencing adequate paralysis of the target muscle that require subsequent injections should receive a dose comparable to the initial dose
  • Subsequent doses for patients experiencing incomplete paralysis of the target muscle may be increased up to two-fold compared to the previously administered dose
  • Subsequent injections should not be administered until the effects of the previous dose have dissipated, as evidenced by substantial function in the injected and adjacent muscles
  • The maximum recommended dose as a single injection for any 1 muscle is 25 Units

Reconstitution and dilution guidelines

The recommended dilution to achieve 1.25 Units is 100 Units/8 mL; for 2.5 Units, it is 100 Units/4 mL for Strabismus.1

Download reconstitution and dilution guidelines for Spasticity and Movement Disorders

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