Figure 2. Seventeen-Year-Old Patient With Mild Botulism

A, Patient at rest. Note bilateral mild ptosis, dilated pupils, disconjugate gaze, and symmetric facial muscles. B, Patient was requested to perform his maximum smile. Note absent periorbital smile creases, ptosis, disconjugate gaze, dilated pupils, and minimally asymmetric smile. As an indication of the extreme potency of botulinum toxin, the patient had 40 x 10^-12g/mL of type A botulinum toxin in his serum (ie, 1.25 mouse units/mL) when these photographs were taken.