• Mail us: support@drtimpearce.com
  • Trustpilot
Dr Tim Pearce, eLearningDr Tim Pearce, eLearningDr Tim Pearce, eLearning Dr Tim Pearce, eLearning
  • eLearning Courses
        • ELEARNING COURSES

        • Techniques
          • BOTOX® Foundation Course
          • Pro Tox
          • Dermal Fillers Foundation Course
          • 8D Lip Design
          • Julie Horne Directs, Dr Tim Injects – February 2023
          • Eyelash Enhancement Serum Course
          • Anatomy360
          • Art Codes
        • Complications
          • Botulinum Toxin Complications Mastery
          • Dermal Filler Complications Mastery
          • Elective Lip Reversal
        • Profinity
        • Wellness
          • How To Introduce Longevity To Your Aesthetics Clinic
        • Marketing
          • DCAM 2.0
          • Canva Mastery: A Step-by-Step Guide
          • Email Marketing Course
          • Industry Photography Secrets
          • How to find your voice with video
        • Other Services
          • DPP for V300 Service
        • Packages
          • Foundation eLearning Package – SAVE 10%
          • Complications eLearning Package – SAVE 10%
          • Techniques eLearning Package – SAVE 20%
          • Marketing eLearning Package – SAVE 20%
          • Full eLearning Package – SAVE 35%
        • Reviews and Testimonials
        • FAQ – Online Courses
  • Downloads
        • Complications
          • 13 Extra Risky Injection Areas: Facial Vessel Map
          • Aspirating Experiment Test Results
          • Bruising Checklist: Prevent & Minimise Bruises from Injectables
          • Dermal Filler Complications: The Essential Guide
          • Delayed Onset Nodules: How To Diagnose And Treat
          • Diagnosing Complications: 7 Steps To Great Advice
          • Emergency Reversal Protocol
          • How To Avoid Causing a Lateral Rectus Palsy From Botulinum Toxins
          • Hyalase Consent Form: Downloadable Template
          • Lumps in Lips Guide: How to Diagnose, Manage & Treat
          • Tear Trough Oedema Protocol
          • Does Covid-19 Vaccine Cause Dermal Filler Reactions?
        • Injection Techniques
          • 26 Essential Injection Patterns For Botulinum Toxin
          • Botox Calculator
          • BOTOX Lesson – Gummy Smile
          • BOTOX Lesson – Hooded Eyes
          • Frequently Used Filler Volumes Facial Map
          • How To Improve Your Needle Control: 6-Step Blueprint
          • How to Prepare BOTOX – Step by Step Guide
        • Consultation Skills
          • Body Dysmorphia & Modification Checklist
          • Is It Safe To Treat? 5-Step Contraindication Check List
          • Medical Model For Cosmetic Procedures: An Essential Guide
        • Lips
          • Lip Consultation Question Checklist
          • Lip Anatomy Lesson
          • Common Needle/Cannula Choices For Lips
          • Lip filler Aftercare Pack for Your Patients
          • Lip Design Blueprint – 4 Steps To Perfect Lip Augmentation
          • Master the Basics of Julie Horne’s Lip Technique
        • Longevity
          • Does HRT Increase Cancer Risk? Guide for Clinicians
          • Educating Patients About How Sugar Exacerbates Aging
          • How to Reduce Biological Age for Your Patients
        • Business & Marketing
          • Annual Profit Calculator
          • 5 Steps to Create a Successful Aesthetics Business
          • Injector’s Cheat Sheet – 7 Social Media Post Types
          • 7 Deadly Hashtag Sins
          • 7 Secret Locations to get Instagram Followers
          • 9 Video Marketing Mistakes
          • 15 Easy Instagram Reels Ideas
          • 3 Time-Saving Hacks for Social Media
          • Personal Branding Starter Kit
          • Value Audit Template: Price-per-1ml
          • World’s Top 5 Filler Brands – Survey Results
  • Blog
  • Products
    • Artistic Anatomy Poster Collection
    • Top 3 Posters Bundle
    • Original Anatomy Poster
    • Beautiful Lip Anatomy Poster
    • Download Pack – Forms & Leaflets
  • About
    • Dr Tim Pearce
    • Miranda Pearce
    • Careers & Recruitment
    • Podcast – Chew the Fatpad
    • Webinars
    • Become a Model
  • Contact
  • Login

Login

Avoiding Botox Eye Complications From Dry Eye to the ‘Psycho Look’

Blogs

  • ALL
  • Complications
  • Injection Techniques
  • Consultation Skills
  • Lips
  • Business & Marketing
You may be interested
Avoiding Botox Eye Complications From Dry Eye to the ‘Psycho Look’

Avoiding Botox Eye Complications From Dry Eye to the ‘Psycho Look’

September 30, 2025

How to Fix a Crooked Smile with Botox

How to Fix a Crooked Smile with Botox

September 25, 2025

Multiple Causes of Vascular Occlusion and Necrosis

Multiple Causes of Vascular Occlusion and Necrosis

September 23, 2025

Temple Filler Brow Drop: Cannula Complications

Temple Filler Brow Drop: Cannula Complications

September 18, 2025

Understanding Facial Danger Zones: A Probabilistic Approach

Understanding Facial Danger Zones: A Probabilistic Approach

September 16, 2025

Avoiding Botox Eye Complications From Dry Eye to the ‘Psycho Look’Dr Tim Pearce
September 30, 2025

When it comes to Botox treatments around the eyes, most injectors focus on getting rid of crow’s feet and achieving that smooth, youthful appearance. But there’s a range of complications that can occur – from the seemingly mild but miserable dry eye syndrome to the concerning appearance of looking “a bit like a psycho” (as one patient memorably described it). Understanding these complications and how to avoid them is crucial for every aesthetic practitioner.

 

Dry Eye: Not Just a Minor Inconvenience

Dry eye sounds like a mild side effect, but anyone who’s experienced it knows better. Having suffered this myself after an eye injury – a piece broke off a router while working on wood and hit me in the eye – I can attest that it’s miserable. I had to treat it for about a month, putting drops into my eye constantly, and it really gets in the way of day-to-day function. If you do this to your patients, it’s certainly not to be dismissed as a mild side effect.

Thankfully, dry eye after Botox is rare and also easy to avoid when you understand the anatomy and injection techniques.

Understanding the Lacrimal Gland Position

The key to avoiding dry eye starts with understanding the position of the lacrimal gland. In 3D anatomical models, you can see the lacrimal gland positioned near the suture between the zygomatic bone and the frontal bone. In many people, it’s probably more superior than typically shown in diagrams based on my cadaver observations, but the important point is it sits in an area where we do inject.

Lacrimal gland anatomy showing position near orbital rim for safe Botox injection technique
Understanding lacrimal gland anatomy is crucial for preventing dry eye complications during periocular Botox treatments

There are two ways you can affect the lacrimal gland:

  1. During lateral canthal treatments – When treating lateral canthal lines (crow’s feet) with a four-unit dose that happens to be positioned too close to the eye
  2. Underneath the eyebrow – When affecting the orbicularis oculi trying to get a little bit of lateral lift

The 1.5 Centimeter Rule

The first principle for avoiding dry eye is to think about the orbital rim as one of the boundaries that you always check and respect. When treating lateral canthal lines, maintain a 1.5 centimeter margin from the orbital rim. This ensures you’re nowhere near the lacrimal gland.

Depth Is Your Defense

The second principle applies to both areas, whether you’re treating underneath the eyebrow or the lateral canthal lines – it’s all about depth. The orbicularis oculi, which is the muscle we’re trying to treat, is superficial. It sits underneath a thin layer of skin, and underneath the muscle is fat.

These layers can be used to defend the lacrimal gland from botulinum toxin:

  • Stay 1.5 centimeters away from the orbital rim
  • Inject very superficially
  • Let the layers of tissue shield the eye

Defending the lacrimal gland is ultimately about being out of the tissue plane that could be affected. If you are superior to it but shielded by the muscle, a layer of fat, and the orbital septum, you’re going to be much less likely to cause dry eye.

The Ledge Effect: When Less Is More

The next area to think about is more of an unwanted effect than a true complication. When you overtreat the lower lateral aspect of the eye trying to eliminate crow’s feet, you can get relaxation of the orbicularis oculi. This then meets the transition point of the zygomaticus major as it pulls up, causing a little ledge.

Facial muscle anatomy diagram showing orbicularis oculi and zygomaticus major for Botox injection planning
The relationship between orbicularis oculi and zygomaticus major muscles affects treatment outcomes and potential ledge formation

Patients will present with a new shadow or ledge on their lid that they don’t like when they smile. They’re not happy even though you’ve clearly gotten rid of all their lines and wrinkles.

The Solution: Dose Reduction

How do we get rid of this problem? It’s really a matter of dose. If you reduce your dose on the lower aspect of the eyelid (I only use two units for nearly all my patients) you get a great result without causing ledges and without causing the next side effect we’ll discuss.

The “Psycho” Look

As described by Julie Bass Kaplan herself from a personal experience with under-eye Botox.

This memorable description captures what happens with descent of the lower lid. When your lower lid descends down, you look a little bit too wide-eyed. As Julie describes, this makes you look a little bit scary in certain instances, and you will see this on many injectors. It comes from over-treating underneath the eye.

The Aging Factor

As you get older and lose collagen and elastin, if you’re treating an area that is basically held together by the muscle and you relax that muscle, you will get descent of the lower lid. Even though the lines and wrinkles may be gone, it just doesn’t look attractive.

Prevention Through Patient Selection

This is quite a common side effect that’s easily avoided by patient selection:

  • Choose patients who have a good snap test (clearly have plenty of collagen and elastin)
  • Use low doses
  • Consent your patients to understand the difference between getting rid of lines and actually looking better

Sometimes you do achieve one outcome (wrinkle reduction) but you don’t get the other (improved appearance).

Ectropion Eyelid: The Rare but Serious Complication

There’s a very rare complication that actually happens in really old people, even if they’ve never had botulinum toxin – the skin quality deteriorates so much that you actually see the pink of the lower lid. This is called an ectropion eyelid, and showing pink underneath the eye is a side effect of tissue that is unable to hold itself in position.

Ectropion eye condition comparison showing healthy eye versus lower eyelid drooping complication
Ectropion, where the lower eyelid droops away from the eye, is a rare but serious complication of excessive periocular Botox

If you add botulinum toxin to someone who’s nearly at that point, you can see how that would bring this problem on. The orbicularis oculi actually holds that lower eyelid against the lower part of the globe, and as you relax it to try and get rid of a line, it then falls outward and you end up with a very unattractive but very rare complication.

I’ve never actually seen a patient get this, though I’ve read about it. It comes from:

  • Poor patient selection
  • Very high doses of botulinum toxin in the lower lid

The Bottom Line: Less Is Often More Under the Eye

To avoid these complications, I do very little treatment underneath the eye. I think it’s only suitable for a very small minority of patients. The reason to do it is not strong in my opinion.

It sometimes helps certain patients with very crinkly skin who are quite young, and you can soften it with a very low dose. But for most patients who have lines under their eyes, they’re actually caused by the zygomatic muscles and the cheek elevators, which squeeze the lower eyelid skin during a smile. So treating orbicularis oculi is only going to have a minimal effect anyway, and sometimes it even makes it worse.

Key Takeaways for Safe Practice

For Dry Eye Prevention:

  • Maintain 1.5cm margin from orbital rim
  • Inject superficially
  • Understand lacrimal gland anatomy
  • Use tissue layers as natural shields

For Lower Lid Complications:

  • Use minimal doses (2 units) in lower lid area
  • Perform snap test before treatment
  • Select appropriate patients (good skin elasticity)
  • Avoid treating elderly patients with poor skin quality

General Principles:

  • Patient selection is crucial
  • Consider whether treatment will actually improve appearance
  • Understand that eliminating lines doesn’t always mean better aesthetics
  • When in doubt, use less product or avoid the area entirely

The Importance of Honest Consultation

It’s worth consenting your patients into understanding the difference between getting rid of lines and wrinkles and actually looking better. Sometimes you achieve one outcome but not the other. This honest approach helps manage expectations and prevents disappointment when lines are gone but the overall appearance isn’t improved – or is even worsened.

Conclusion: Mastery Through Understanding

These complications – from dry eye to the “psycho look” to ectropion – are all avoidable with proper technique, appropriate patient selection, and conservative dosing. The key is understanding not just how to inject, but when NOT to inject.

Remember, the area underneath the eye is challenging territory. Unless you’ve got a very clear reason why you think it’s going to work on your particular patient, it’s often better to avoid it altogether. The risk-benefit ratio simply isn’t favorable for most patients.

By following these guidelines – respecting anatomical boundaries, using appropriate depths, selecting suitable patients, and using conservative doses – you can deliver safe, effective treatments that enhance rather than compromise your patients’ appearance.

Ready to master advanced facial anatomy and develop real confidence in high-risk injection areas?

Join our exclusive webinar where we dive deep into safe injection techniques and complication management. Click here to save your free spot on the next webinar >  

Anatomy360 - The Ultimate 3D Anatomy Course

Dr Tim Pearce's anatomy course delivers a thorough understanding of facial anatomy through 12 online lessons. Tim says:

“The problem is we’re taught anatomy in 2D textbooks, but real-life anatomy isn’t flat. In order to feel confident with injecting and to get that millimetre by millimetre precision that increases safety, we need more detail.

“That’s why I’ve created the ultimate Anatomy learning experience specifically for aesthetic injectors. It’s going to help you up-level your anatomy knowledge and boost your injection safety & confidence in a way that no cadaver course could ever.”

Find out more about Dr Tim Pearce's Anatomy360 Course.

Anatomy360 Course

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.

Share This Article
Facebook Twitter Pinterest Linkedin
Prev Post

Related Articles

How to Fix a Crooked Smile with Botox Bestseller

How to Fix a Crooked Smile with Botox

September 25, 2025

How to Fix a Crooked Smile with Botox
By Andrea Callaway
September 25, 2025

How to Fix a Crooked Smile with Botox

READ MORE
Multiple Causes of Vascular Occlusion and Necrosis Bestseller

Multiple Causes of Vascular Occlusion and Necrosis

September 23, 2025

Multiple Causes of Vascular Occlusion and Necrosis
By Andrea Callaway
September 23, 2025

Multiple Causes of Vascular Occlusion and Necrosis

READ MORE
Temple Filler Brow Drop: Cannula Complications Bestseller

Temple Filler Brow Drop: Cannula Complications

September 18, 2025

Temple Filler Brow Drop: Cannula Complications
By Andrea Callaway
September 18, 2025

Temple Filler Brow Drop: Cannula Complications

READ MORE

Add your Comment

Popular Courses

BOTOX® Foundation Course

BOTOX® Foundation Course

Pro Tox

Pro Tox

8D Lip Design

8D Lip Design

SEE MORE

CONTACT US

    contact injection
    Dr Tim Pearce

    Improve your medical
    aesthetics business

    • Home
    • Courses
    • About
    • Contact
    • Terms & Conditions
    • Privacy Policy
    • Website Terms Of Use
    • Careers
    Login Dr Tim Pearce Login
    © Copyright Dr Tim Ltd, 2025
    We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Read More. By clicking “Accept All”, you consent to the use of ALL the cookies. However, you may visit "Cookie Settings" to provide a controlled consent.
    Cookie SettingsAccept All
    Manage consent

    Privacy Overview

    This website uses cookies to improve your experience while you navigate through the website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may affect your browsing experience.
    Necessary
    Always Enabled
    Necessary cookies are absolutely essential for the website to function properly. These cookies ensure basic functionalities and security features of the website, anonymously.
    CookieDurationDescription
    cookielawinfo-checkbox-analytics11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
    cookielawinfo-checkbox-functional11 monthsThe cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
    cookielawinfo-checkbox-necessary11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
    cookielawinfo-checkbox-others11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
    cookielawinfo-checkbox-performance11 monthsThis cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
    viewed_cookie_policy11 monthsThe cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.
    Functional
    Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features.
    Performance
    Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors.
    Analytics
    Analytical cookies are used to understand how visitors interact with the website. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc.
    Advertisement
    Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. These cookies track visitors across websites and collect information to provide customized ads.
    Others
    Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet.
    SAVE & ACCEPT