Epidemiology of primary blepharospasm

Blepharospasm Secondary to Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson Disease: Clinical Characteristics and Management Outcomes

BACKGROUND

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an effective treatment for patients with motor symptoms of Parkinson disease but can be complicated by disabling blepharospasm and apraxia of eyelid opening (ALO). Currently, there is no clear consensus on optimal management, and addressing these issues is further hindered by systemic morbidity and resistance to treatments. We aim to describe the different phenotypes of these eyelid movement disorders, to report our management approach and patient responses to treatment.

METHODS

A retrospective case series of all patients with blepharospasm/ALO secondary to STN-DBS that were treated at a tertiary center between 2011 and 2020. Data collected included date of Parkinson diagnosis, date of DBS surgery, date of development of blepharospasm/ALO symptoms, STN-DBS stimulation settings, and treatment given. Patients' symptoms before and after treatment were measured using the blepharospasm disability index and Jankovic Rating Scale.

RESULTS

Five patients were identified with eyelid movement disorders secondary to STN-DBS. All patients had moderate-to-severe symptoms at presentation. Four patients received periocular botulinum toxin injections. Three patients underwent surgery in the form of frontalis suspension or direct brow lift with or without upper lid blepharoplasty. All reported an improvement in symptoms following treatment.

CONCLUSIONS

A multimodality, patient-specific approach is required in the treatment of blepharospasm/ALO secondary to STN-DBS. Botulinum toxin injections can be effective, but patients may require surgery if toxin treatment alone becomes ineffective. Tailoring treatment to individual needs can result in a measurable improvement in symptoms.

The effect on blink frequency of a selective blue-filtering photochromic lens in patients with benign essential blepharospasm

Objective

The aim of this clinical study was to assess the impact of a non-invasive selective blue-filtering photochromic lens coating Crizal Prevencia on the treatment and response of benign essential blepharospasm (BEB).

Patients and methods

Twenty-four patients were recruited in the outpatient clinic of the Medical University of Vienna in a randomized, double-blind, cross-over study design. Blink frequencies were assessed in patients with BEB before and 14 days after intervention with either a filtering ophthalmic lens or a placebo lens, respectively. Outcome parameters include sub-group analysis of a blink frequency under six different conditions: three photopic conditions, one resting condition, one reading condition, and one video game condition.

Results

From 24 recruited patients, 15 patients were available for final analysis. Comparing the optical blue filtering lens to placebo, showed a reduced blink frequency in specific subtests, but not compared to baseline.

Discussion

In conclusion, optical filtering glasses might have a beneficial effect on BEB and provide a non-invasive therapeutic add-on option, in addition to botulinum neurotoxin therapy, for patients with BEB and should necessarily be further investigated in a multicenter setting, resulting in larger sample sizes to gain valid information about the effect of photochromic blue filter glasses in BEB.Clinical trial registration: https://drks.de/search/en/trial/DRKS00032135, DRKS00032135.

Treatment of strabismus and blepharospasm with Botox (onabotulinumtoxinA): Development, insights, and impact

Strabismus, deviation of the ocular alignment, can adversely affect quality of life and activities of daily living. Surgery was the prior standard of care for strabismus, but up to 40% of patients required additional surgeries. This need for more effective and less invasive treatment, along with the convergence of other events such as the development of electromyography, purification of botulinum toxin A, and the finding that injection of botulinum toxin type A could paralyze the hind limbs of chicks, led Dr. Alan Scott to investigate injection of his formulation for strabismus. The positive results of initial trials in monkeys segued to human trials with observations of alignment improvements and few adverse events. The success of botulinum toxin type A in the treatment of strabismus led to interest in its use to treat other skeletal muscles, particularly in blepharospasm, a type of focal dystonia involving eyelid spasms and involuntary eye closure that lacked an effective pharmacological treatment. Patient groups helped to increase awareness of this novel treatment, and results from clinical trials confirmed its effectiveness. Dr. Scott's formulation, then known as Oculinum, received its first Food and Drug Administration approvals in 1989 for strabismus and blepharospasm. Allergan acquired Oculinum in 1991, renaming it Botox. These initial uses led to its application in a myriad of other indications as outlined in other articles of this supplement.

Health-related quality of life of daily-life-affected benign essential blepharospasm: Multi-center observational study

PURPOSE

To compare Thais' health-related quality of life (HRQOL) and severity grading, efficacy and safety in daily-life-affected benign essential blepharospasm (BEB) patients at baseline and after Botulinum toxin type A (BTX-A) treatment.

DESIGN

Prospective-observational study.

PARTICIPANTS

BEB patients with Jankovic rating scale (JRS) at least 3 in both severity and frequency graded from 14 institutes nationwide were included from August 2020 to June 2021.

METHODS

Demographic data, HRQOL evaluated by the Thai version of EQ-5D-5L and NEI-VFQ-25 questionnaires, and severity grading score evaluated by Jankovic rating scale (JRS) at baseline, 1, and 3 months after the treatment were collected. The impact of the BTX-A injections and their complications were recorded.

RESULTS

184 daily-life-affected BEB patients were enrolled; 159 patients (86.4%) had complete data with a mean age of 61.40±10.09 years. About 88.05% were female, and 10.1% were newly diagnosed. Most of the patients had bilateral involvement (96.9%) and 12.6% had history of BEB-related accident. After BTX-A treatment, HRQOL improved significantly in 4 dimensions of EQ-5D-5L, except self-care. The EQ_VAS (mean±SD) was 64.54±19.27, 75.13±15.37, 73.8±15.85 (p<0.001) and EQ-5D-5L utility score was 0.748±0.23, 0.824±0.19 and 0.807±0.19 at baseline, 1, 3 months after treatment, respectively. From NEI-VFQ-25, HRQOL also improved in all dimensions, except eye pain. The JRS improved in all patients. Self-reported minor adverse events were 22.6%, which mostly resolved within the first month.

CONCLUSION

Daily-life-affected BEB impacted HRQOL in most dimensions from both generic and visual-specific questionnaires. BTX-A treatment not only decreased disease severity, but also improved quality of life.

A dual dopaminergic therapy with L-3,4-dihydroxyphenylalanine and chlorpromazine for the treatment of blepharospasm, a focal dystonia: Possible implications for striosomal D1 signaling

Impairment of balanced activity between dopamine D1 and D2 receptor functions in the striatum, particularly in striatal functional subdivisions (i.e., striosome and matrix compartments), has been proposed to underlie dystonia genesis. This study was undertaken to examine the therapeutic effect of dual dopaminergic modulation with L-3,4-dihydroxyphenylalanine (L-DOPA) and chlorpromazine (CPZ) in patients with blepharospasm, a focal dystonia. For this purpose, Dopacol tablets™ (L-DOPA 50 mg plus carbidopa 5 mg) and Wintermin™ (CPZ phenolphthalinate 180 mg/g) were used. Clinical evaluations were performed before and after an 8-week drug treatment interval using the Visual Analog Scale (VAS), Blepharospasm Disability Index (BSDI), modified VAS (mVAS), and Jankovic Rating Scale (JRS). The data were analyzed using non-parametric statistics. Results showed that in patients (n = 7) with blepharospasm, dystonia symptoms were significantly alleviated by the administration of both Dopacol tablets™ (one tablet × 3/day) and CPZ (5 mg × 3/day), as determined using the VAS, BSDI, mVAS, and JRS. In contrast, there was no improvement of dystonia symptoms in patients (n = 7) who ingested Dopacol tablets™ (one tablet × 3/day) alone, nor in those (n = 7) who ingested CPZ (5 mg × 3/day) alone. Thus, dual pharmacotherapy with L-DOPA and CPZ can exert a therapeutic effect on blepharospasm, suggesting that dystonia symptoms can be attenuated through dopaminergic modulation with inducing an increase in striatal D1-signals. Since dopamine D1 receptors are heavily enriched in the striosome compartment in the “human” striatum, our results also suggest that striosomal loss of D1-signaling may be important in the pathogenesis of dystonia.

[Dry eye and qualitative tear alteration in essential blepharospasm]

PURPOSE

We aimed to analyze the tears of patients with Benin Essential Blepharospasm (BEB) to explore possible corneo-conjunctival mechanisms for photophobia, tear deficiency and ocular pain.

METHODS

Using an observational cohort of 42 patients diagnosed with BEB, we performed Schirmer's testing, measurement of tear film pH, tear film protein electrophoresis and conjunctival impression cytology.

RESULTS

Schirmer's testing showed dry eye (8.4±9.7mm) with 71.3% eyes having a Schirmer's score<10mm. Surprisingly, the pH was basic (8.4±0.4) and was improved in patients receiving the standard treatment of quarterly botulinum toxin injections (8.32±0.36 for treated patients vs. 8.74±0.53 for untreated patients; P=0.045). Together, tear protein electrophoresis and conjunctival impression cytology showed conjunctival inflammation associated with BEB.

CONCLUSION

For the first time, this study emphasizes corneo-conjunctival mechanisms to explain the photophobia, dry eye and pain in Benign Essential Blepharospasm. While encouraging, complementary studies remain necessary to evaluate the effect of correcting tear film pH and inflammation on the quality of life of blepharospasm patients.

Ultra-Long-Term Therapy of Benign Essential Blepharospasm with Botulinumtoxin A—30 Years of Experience in a Tertiary Care Center

Aim of this study was to investigate the long-term results of botulinum toxin A (BoNT-A) injections for the treatment of benign essential blepharospasm (BEB) and to report our experience with (ultra-)long-term treatment with onabotulinumtoxin-A. We conducted a retrospective cross-sectional analysis at a university hospital. Patients with BEB and BoNT-A treatment were assigned to the Total Blepharospasm Group, patients with ≥21 onabotulinumtoxin-A injections to the Ona Long-Term Group. The Total Blepharospasm Group (n = 1940) included 33,933 BoNT-A injections. The age of patients at symptom onset was (mean ± SD) 58.0 ± 13.1 years, and 70.4% were female. The Ona long-term group (n = 234) included 10,632 onabotulinumtoxin-A injections. In this group, patients received 45.4 ± 22.9 injections with a mean dose of 22.2 IU ± 0.5. The duration of treatment was 12.6 ± 5.4 years, ranging from 2.9 to 30.0 years. The effect–duration–dose quotient did not change during long-term treatment. The observed side effects were comparable in type and frequency to other studies, even with the (ultra-)long treatment with onabotulinumtoxin-A. Our results, based on one of the largest patient populations and a treatment duration of up to 30 years, impressively demonstrate that onabotulinumtoxin-A is a safe and effective therapy for essential blepharospasm, even in the ultra-long term.

Sex related differences in nonmotor symptoms of patients with idiopathic blepharospasm

Idiopathic blepharospasm shows a female predominance in prevalence, whether there are sex-related differences in distributions of nonmotor symptoms (NMSs) and predictors of quality of life are unknown. Four hundred and twenty-five patients with idiopathic blepharospasm were consecutively recruited, and underwent assessments including dystonia severity, mood disturbances, sleep disturbances, cognition, ocular symptoms, and quality of life. Frequencies and distributions of NMSs, and predictors of quality of life in female and male patients were investigated. NMSs existed in majority of male (94.0%) and female (95.8%) patients. The frequencies of depression, cognition dysfunction, and poor sleep quality were higher in female patients, while the frequency of excessive daytime sleepiness was higher in male patients. More female (79.5%) patients had multiple NMS domains affected than male (70.1%) patients (p = 0.040). Quality of life was associated with depression, anxiety and motor severity for female patients (adjusted R² = 0.367, p < 0.001), while associated with depression, excessive daytime sleepiness and motor severity for male patients (adjusted R² = 0.430, p < 0.001). The highly prevalent coexistence of multiple NMSs found in patients with blepharospasm support that blepharospasm is a network disorder. The sex-related differences in the pattern of NMSs and predictors of quality of life may aid the development of tailored management of blepharospasm.

Botulinum toxin for benign essential blepharospasm: A systematic review and an algorithmic approach

BACKGROUND

Currently, there is no standardised approach for benign essential blepharospasm treatment with botulinum toxin, and controversies still exist regarding this subject.

OBJECTIVE

The objective of this systematic review is to summarise and compare all the published data regarding benign essential blepharospasm treatment with botulinum toxin.

METHODS

On October 3, 2018, an online search of the Medline database was conducted. All articles with a detailed description of their botulinum toxin injection technique for benign essential blepharospasm were included in this review.

RESULTS

Five studies were selected for inclusion with a total of 854 patients. Four of the included studies used onabotulinumtoxin A and one study used abobotulinumtoxin A. All studies injected the pretarsal orbicularis occuli muscle. The preseptal orbicularis occuli was injected in four studies, and the preorbital muscle in three studies. The most commonly used method of evaluation was the Jankovic Rating Scale. Adverse events were transient, and dose related. Ptosis was more frequently encountered with the preseptal orbicularis injections.

CONCLUSION

Botulinum toxin injection for benign essential blepharospasm is a non-invasive and safe procedure. The pretarsal muscle should be considered as the key component when treating benign essential blepharospasm with botulinum toxin. We developed an algorithmic approach to the treatment of benign essential blepharospasm with botulinum toxin. However, further randomised controlled trials are warranted.

Personality profile of the primary blepharospasm (BSP): An investigation using the Minnesota Multiphasic Personality Inventory

OBJECTIVE

To explore whether patients with blepharospasm (BSP) have abnormal personality traits by the Minnesota Multiphasic Personality Inventory (MMPI) questionnaire.

METHOD

The personality profiles of patients with BSP and its relationship with clinical characteristics were assessed in this research. 46 patients with BSP and 33 age-and-gender matched healthy controls were assessed using the MMPI questionnaire. The scores of three validity scales and ten clinical scales were calculated and compared. Then the relationship between those scales and clinical characteristics of patients with BSP was analyzed in the BSP group.

RESULTS

It was found that patients with BSP scored significantly higher than healthy controls on the D, Hy, Pt clinical scales. The peak values of profiles were Hy, D, Hs scale scores. However, there was no statistical relationship between the clinical scales of MMPI and the clinical characteristics of BSP after Bonferroni Correction.

CONCLUSION

The findings indicated that MMPI could be a useful psychometric tool to characterize a specific pattern of the personality of BSP patients and BSP patients may have avoidant and somatization personality characteristics.

Which factors impact on quality of life for adults with blepharospasm and hemifacial spasm?

Purpose: Benign essential blepharospasm (BEB) and hemifacial spasm (HFS) are debilitating conditions causing spasms to the eyes and/or face and can significantly impact on quality of life (QoL). Initial research has highlighted potential factors impacting on QoL in BEB, but there remains a wealth of demographic, clinical, and psychosocial factors that may contribute to QoL but have not received attention. Methods: Cross-sectional baseline data were collected before a single-masked randomised controlled trial from 130 adults with BEB and HFS recruited from botulinum toxin clinics at Moorfields Eye Hospital, London. QoL was measured using the 24-item Craniocervical Dystonia Questionnaire (CDQ24), which provides a total score and five subscale scores relating to Stigma, Emotional state, Pain, Activities of daily living (ADL), and Social/family life. Treating clinicians provided clinical data. Hierarchical multiple regressions were performed on this baseline data to identify significant predictors of QoL. Results: ADL and Stigma were the areas most impacted upon whilst patients experienced better adjustment in relation to Pain, Social/family life, and Emotional state. CDQ24 Total scores were explained by the model (80% variance) and were significantly associated with appearance concerns, emotional representations, perceived negative consequences of the condition, mood, and dose of botulinum toxin. Conclusions: Patients with BEB and HFS report a detrimental impact on ADL and perceived stigma in relation to their condition. Predominantly, individual perceptions and mood are associated with QoL in this population, rather than demographic and clinical factors, signifying areas to target in the design of future healthcare services or interventions.

Long-term treatment of blepharospasm with botulinum toxin A: a service-based study over a 16-year follow-up in southern China

OBJECTIVE

To elucidate the effect of long-term treatment with botulinum toxin A (BTX-A) for blepharospasm. Prevalence data and clinical features in southern China and influencing factors for selecting BTX-A treatment were explored.

METHODS

We collected data retrospectively from 338 consecutive patients diagnosed with blepharospasm over 16 years to assess prevalence data and clinical features. Thereafter, all patients were classified into BTX-A (n = 135) or non-BTX-A (n = 203) treatment groups according to the patients' requests in order to explore the factors influencing whether BTX-A treatment was chosen. Furthermore, dynamic follow-up data were analyzed to evaluate the long-term efficacy in the BTX-A group.

RESULTS

The prevalence was 23.3 per million, with an onset age of 50.3 ± 12.3 years and a female:male ratio of 2.4:1; the most common symptom was excessive blinking (91.2%). The symptom severity and psychological assessment scores were significantly decreased by treatment with BTX-A (p < 0.01), and there was no significant difference in response duration with the prolongation of BTX-A injections. Adverse events occurred 52 times (5.0%) among 1038 injections. The symptom severity and psychological assessment scores and the occurrence of eye-opening difficulty were higher, and medical expenses and the symptom tolerability rate were lower in the BTX-A group than in the non-BTX-A group (p < 0.05).

CONCLUSION

The onset age was earlier than that in Western countries. However, starting BTX-A treatment early is justified, even though a higher dosage was needed to maintain reliable long-term efficacy. Additionally, symptom severity and medical expenses are the primary factors affecting whether patients select BTX-A treatment.

Epidemiology of benign essential blepharospasm: A nationwide population-based retrospective study in Taiwan

IMPORTANCE

This study provides a nationwide, population-based data on the incidence of benign essential blepharospasm in Asian adults.

BACKGROUND

To describe the incidence, patient demographics, and risk factors associated with benign essential blepharospasm.

DESIGN

Population-based retrospective study.

PARTICIPANTS AND SAMPLES

A total of 1325 patients with benign essential blepharospasm were identified.

METHODS

Patients with diagnosis of blepharopsasm between January 2000 and December 2013 were sampled using the Longitudinal Health Insurance Database 2000. Secondary blepharospasm that may be related to neurological, trauma, and ocular surface disease were excluded.

MAIN OUTCOME MEASURED

Multivariate conditional logistic regression was used to estimate the odds ratios for potential risk factors of benign essential blepharospasm.

RESULTS

The mean annual incidence was 0.10‰ (0.07‰ for males, and 0.12‰ for females). The peak incidence was in the 50 to 59-year-old age group (0.19‰). People living in urban regions have more risk of developing blepharospasm comparing to people living in less urban regions (p <0.01). White-collar workers also have higher chance of having blepharospasm (p<0.001). Significant difference between control group and case group in hyperlipidemia (p <0.001), sleep disorders (p <0.001), mental disorders (depression, anxiety, obsessive compulsive disorder) (p <0.001), dry eye-related diseases (dry eye, Sjögren's syndrome) (p <0.001), Parkinson's disease (p <0.004), and rosacea (p <0.021) were also identified.

CONCLUSIONS AND RELEVANCE

Higher level of urbanization, white-collar work, sleep disorders, mental health diseases, dry eye-related diseases, Parkinsonism, and rosacea are possible risk factors for benign essential blepharospasm.

Clinical Features of Benign Essential Blepharospasm in Korean Patients

Purpose

To analyze the clinical features of benign essential blepharospasm in Korean patients.

Methods

Patients diagnosed with benign essential blepharospasm in Kim's Eye Hospital from November 2014 to December 2016 were evaluated using a clinical examination and questionnaire. The questionnaire reviewed personal medical history, demographic factors, risk factors for blepharospasm development, and relieving and aggravating factors.

Results

Of the 101 patients enrolled, 78 (77.2%) were women. The mean age was 64.9 years old. Hypertension was the most common medical disorder (42.6%), followed by diabetes mellitus. The majority of the patients were non-smokers (83.2%) and drank less than a cup of a caffeinated beverage a day (30.7%). Fifty-seven percent of patients reported no stressful events immediately prior to symptom development. Fatigue and stress were aggravating factors in more than 55% of patients; rest was the most common relieving factor (35.6%).

Conclusions

Here, we report the clinical features of benign essential blepharospasm in Korean patients for the first time. The results were consistent with previous reports showing that the majority of benign essential blepharospasm patients are women and non-smokers. In contrast to previous reports though, fatigue and stress were aggravating factors, and the most common relieving factor was rest. No stressful events had immediately preceded the development of blepharospasm in 57.4% of patients. This report may aid in treating and counseling patients with benign essential blepharospasm.

Effects of Repeated Eyelid Injections with Botulinum Toxin A on Innervation of Treated Muscles in Patients with Blepharospasm

PURPOSE

To assess changes in innervation and muscle morphology after repeated botulinum toxin A injections in subjects with benign essential blepharospasm.

METHODS

Surgical waste specimens were processed for histologic examination of nerve fibers, neuromuscular junctions, fiber size, and central nucleation and compared to age matched controls and to two subjects with blepharospasm that had not received botulinum toxin A injections.

RESULTS

There was a significant increase in amount of nerve fibers and numbers of neuromuscular junctions in the orbicularis oculi muscles from subjects with blepharospasm treated repetitively with botulinum toxin A. In addition there was a significant decrease in mean muscle fiber cross-sectional area and an increase in central nucleation. The specimens from the subjects with only blepharospasm had the same density of nerves but had intermediate levels of neuromuscular junctions.

CONCLUSIONS

These data suggest that repeated injections of botulinum toxin A has an effect on nerve and neuromuscular junction numbers, which are partly mirrored in orbicularis oculi muscle from subjects with blepharospasm only. These studies suggest the potential for modulating these changes in order to extend the duration of effectiveness of botulinum toxin.

Surgical approach to limiting skin contracture following protractor myectomy for essential blepharospasm

Purpose

To report our experience with protractor myectomy in patients with benign essential blepharospasm who did not respond to serial botulinum toxin injection, and to describe intra- and postoperative techniques that limited skin contracture while also providing excellent functional and cosmetic results.

Methods

The medical records of patients with isolated, benign, essential blepharospasm who underwent protractor myectomy from 2005 to 2008 by a single surgeon were reviewed retrospectively. The technique entailed operating on a single eyelid during each procedure, using a complete en bloc resection of all orbicularis tissue, leaving all eyelid skin intact at the time of surgery, and placing the lid under stretch with Frost suture and applying a pressure dressing for 5-7 days.

Results

Data from 28 eyelids in 7 patients were included. Average follow-up was 21.5 months (range, 4-76 months). Of the 28 eyelids, 20 (71.4%) showed postoperative resolution of spasm, with no further need for botulinum toxin injections. In the 8 eyelids requiring further injections, the average time to injection after surgery was 194 days (range, 78-323 days), and the average number of injections was 12 (range, 2-23 injections). All but one eyelid had excellent cosmetic results, without signs of contracture; one eyelid developed postoperative skin contracture following premature removal of the Frost suture and pressure dressing because of concerns over increased intraocular pressure.

Conclusions

In our patient cohort, this modified technique resulted in excellent cosmetic and functional results and limited postoperative skin contracture.

Eyelid Dysfunction in Neurodegenerative, Neurogenetic, and Neurometabolic Disease

Eye movement abnormalities are among the earliest clinical manifestations of inherited and acquired neurodegenerative diseases and play an integral role in their diagnosis. Eyelid movement is neuroanatomically linked to eye movement, and thus eyelid dysfunction can also be a distinguishing feature of neurodegenerative disease and complements eye movement abnormalities in helping us to understand their pathophysiology. In this review, we summarize the various eyelid abnormalities that can occur in neurodegenerative, neurogenetic, and neurometabolic diseases. We discuss eyelid disorders, such as ptosis, eyelid retraction, abnormal spontaneous and reflexive blinking, blepharospasm, and eyelid apraxia in the context of the neuroanatomic pathways that are affected. We also review the literature regarding the prevalence of eyelid abnormalities in different neurologic diseases as well as treatment strategies (Table 1).

Improvement of Orbitofrontal Cortex Function Associated with Blephrospasm Symptom Remission

OBJECTIVE

To determine whether orbitofrontal cortex (OFC) function improves with blepharospasm (BSP) symptom remission using a verbal fluency task and near-infrared spectroscopy (NIRS).

METHODS

Nineteen BSP patients and 9 healthy controls (HCs) matched by gender and education were examined using NIRS. The BSP patients were divided into 2 groups based on the onset or remission of BSP symptoms. A covariance analysis was conducted to analyze the differences among the 3 groups to avoid the influence of different ages. The least significant difference was used to process the post hoc test.

RESULTS

The hemoglobin concentration and cerebral blood flow of the bilateral orbitofrontal area (channels 27, 31, 34, 37, and 39) were not significantly different between the BSP remission and HC groups (p > 0.05); however, both groups were significantly increased compared with the BSP onset group (BSP remission group vs. BSP onset group: p = 0.003, p = 0.018, p = 0.013, p = 0.001, and p = 0.011, respectively; BSP remission group vs. BSP onset group: p = 0.037, p = 0.044, p = 0.023, p = 0.016, and p = 0.025, respectively).

CONCLUSION

This is the first investigation to control for symptom stages in BSP patients examined via NIRS. Cognitive ability and OFC function improve with BSP symptom remission. Thus, the OFC may be inter-connected with motor and cognitive symptoms in BSP.

Symptomatic Models of Parkinson's Disease and L-DOPA-Induced Dyskinesia in Non-human Primates

Models of Parkinson's disease (PD) can be produced in several non-human primate (NHP) species by applying neurotoxic lesions to the nigrostriatal dopamine pathway. The most commonly used neurotoxin is MPTP, a compound accidentally discovered as a contaminant of street drugs. Compared to other neurotoxins, MPTP has the advantage of crossing the blood-brain barrier and can thus be administered systemically. MPTP-lesioned NHPs exhibit the main core clinical features of PD. When treated with L-DOPA, these NHP models develop involuntary movements resembling the phenomenology of human dyskinesias. In old-world NHP species (macaques, baboons), choreic and dystonic dyskinesias can be readily distinguished and quantified with specific rating scales. More recently, certain non-motor symptoms relevant to human PD have been described in L-DOPA-treated MPTP-NHPs, including a range of neuropsychiatric abnormalities and sleep disturbances. The main shortcomings of MPTP-NHP models consist in a lack of progression of the underlying neurodegenerative lesion, along with an inability to model the intracellular protein-inclusion pathology typical of PD. The strength of MPTP-NHP models lies in their face and predictive validity for symptomatic treatments of parkinsonian motor features. Indeed, these models have been instrumental to the development of several medical and surgical approaches that are currently applied to treat PD.

Clinical Analysis of Patients with Primary Blepharospasm: A Report of 100 Cases in China

PURPOSE

This study explored the clinical characteristics, diagnosis and treatments of primary blepharospasm.

METHODS

In this retrospective analysis, 100 patients with blepharospasm were enrolled. Data were collected from medical records and face-to-face interviews with patients and their families.

RESULTS

The age of onset was 56.4 ± 2.7 (range, 32-76 years). The duration between onset and accurate diagnosis was 38.7 ± 36.0 months (range, 2-120 months). Dry eyes occurred in 54% of the patients. The initial diagnostic accuracy was 10%. Dry eye syndrome, conjunctivitis/keratitis and myasthenia gravis caused the most confusion in the differential diagnosis. Regular botulinum toxin type A injections improved both eyelid spasms and subjective ocular symptoms in all patients.

CONCLUSIONS

Regular botulinum toxin type A injections improved both eyelid spasms and subjective ocular symptoms in blepharospasm patients. The differentiation of primary blepharospasm differentiation from dry eye syndrome, conjunctivitis/keratitis and myasthenia gravis must be improved.

Botulinum toxin in the management of blepharospasm: current evidence and recent developments

Blepharospasm is a focal (although usually bilateral) dystonia of the orbicularis oculi muscles, producing excessive eye closure. This produces significant disability through functional blindness. Botulinum neurotoxins (BoNT) have become the treatment of choice for blepharospasm; the impressive response rate and the tolerable safety profile have been proven through multiple clinical studies. There are currently four BoNT approved in the United States for different indications - we review the data on blepharospasm for each of these drugs. Currently, incobotulinumtoxinA and onabotulinumtoxinA have the most evidence of benefit for patients with blepharospasm. Current evidence, recent development and future directions are discussed.

Comparable Botulinum Toxin Outcomes between Primary and Secondary Blepharospasm: A Retrospective Analysis

Background

Blepharospasm is a focal cranial dystonia, which could be idiopathic in origin or secondary to an underlying disorder that commonly impairs quality of life. Botulinum toxin (BoNT) injections have become the treatment of choice; however, a less favorable response to BoNT is expected in secondary blepharospasm. No studies have been conducted comparing outcomes between blepharospasm cohorts. We therefore aim to compare BoNT outcomes in primary and secondary blepharospasm subjects.

Methods

A retrospective review of 64 blepharospasm subjects receiving BoNT therapy was conducted. Demographics, BoNT treatment schedules, duration of BoNT therapy, and side effects were recorded. Outcome measures were duration of benefit, peak-dose benefit recorded with the Clinical Global Impressions Scale (CGIS), and related side effects.

Results

No difference was found between the two cohorts regarding duration of benefit from treatment (primary 9.47 weeks vs. secondary 9.63 weeks, p = 0.88). Perceived peak-dose benefit was more commonly reported as “very much improved” in secondary patients, but this was not significant (p = 0.13). Higher BoNT dosages were required in both groups over time, with a mean increase of 20.5% in primary and 26.5% in secondary blepharospasm. Ptosis (8%) and diplopia (6%) were the most common reported side effects. Mean follow-up in years was similar between groups, 3.6 years for primary vs. 2.4 years for secondary blepharospasm (p = 0.17).

Discussion

BoNT injections were effective with comparable benefits seen in both primary and secondary blepharospasm populations. Clinicians should be aware of the similar benefit from BoNT reported in secondary blepharospasm patients. The average duration of benefit in this cohort was comparable with previous reports.

Long-term efficacy and safety of botulinum toxin A injections to treat blepharospasm and hemifacial spasm

BACKGROUND

To evaluate efficacy and safety of botulinum toxin A injections after more than 10 consecutive years of treatment for benign essential blepharospasm and hemifacial spasm.

DESIGN

Retrospective chart review at university-affiliated hospital.

PARTICIPANTS

Study consisted of 64 patients treated with botulinum toxin A injections between October 2005 and May 2006.

METHODS

Inclusion criteria included patients treated with at least one annual botulinum toxin-A injection for more than 10 consecutive years. Data collected included diagnoses and patient characteristics, injection dates, doses administered at each visit, response scores, duration of effect, and adverse events.

MAIN OUTCOME MEASURES

Included changes in doses, response scores, duration of effects, and adverse events between the first and last botulinum toxin A injections.

RESULTS

Thirty-two of 64 patients (mean age at first injection, 57.2 ± 12.4 years; 25 women) met the inclusion criteria. The mean duration of follow up was 14.1 ± 3.1 years (range 10-20 years; mean total visits 44.4 ± 19). A higher mean injection dose per visit was administered during the last year compared with the first year (26.8 ± 10.3 vs. 22.5 ± 7.5 units, respectively) (P = 0.003). The mean durations of effect during the first and last years were 12.4 ± 7.1 and 14.6 ± 7.0 weeks, respectively (P = 0.076). There were no significant differences between genders or between benign essential blepharospasm and hemifacial spasm subgroups. The most common adverse events were ptosis, lagophthalmos and dry eye.

CONCLUSIONS

Botulinum toxin A is an effective, safe, long-term treatment for patients with benign essential blepharospasm and hemifacial spasm. Sustained treatment efficacy required higher doses; however, fewer adverse reactions developed.

A comparison of facial muscle squeezing versus non-facial muscle squeezing on the efficacy of botulinumtoxin-A injections for the treatment of facial dystonia

BACKGROUND

This study was performed to address whether voluntary muscle squeezing post botulinum toxin-A treatment with increased neuronal activity translates into noticeable patient benefit in practice.

METHODS

This was a prospective, consecutive, double crossover interventional study. Participants were receiving regular (3 monthly) botulinum toxin-A treatment for aberrant facial nerve regeneration (AFNR), benign essential blepharospasm (BEB) or hemifacial spasm (HFS). Twenty-six participants were recruited and these were randomised into two groups (A and B). Group A performed a program of intensive facial exercises for 5 minutes after their first and third treatment whereas after their second treatment, they were asked to rest in a seated position for 5 minutes, and instructed not to talk or perform any voluntary movements of their face. Conversely group B were only asked to perform squeezing exercises after their second treatment. Outcomes were evaluated objectively using video-recordings and subjectively by questionnaire and telephone interview of participants.

RESULTS

Video-recording data was complete for 21 participants. There was a mean 40% reduction in the frequency of facial muscle spasms and a 33% lower severity score (video-recordings graded by 1 masked investigator) where intensive facial exercises were performed post-treatment. These findings did not reach statistical significance (Mann- Whitney two-tailed test; p = 0.367).

CONCLUSION

Although statistical significance was not achievable, this study suggested a possible trend towards an increased efficacy of botulinum toxin-A, with facial muscle squeezing post BTX treatment. Future studies with a larger number and a better defined subset of subjects may lead to statistical significance.

Blepharospasm in a patient with pontine capillary telangiectasia

Blepharospasm is rarely due to an identifiable etiology. In the majority of cases, imaging fails to reveal any structural lesion. Here we describe an otherwise healthy patient with blepharospasm who was found to have pontine capillary telangiectasia. We propose a potential association between blepharospasm and pontine capillary telangiectasia.

Nondopaminergic treatments for Parkinson’s disease

SUMMARY The main treatment strategy for Parkinson’s disease (PD) is focused on dopamine replacement. However, PD is no longer seen purely as a disease of the dopaminergic system, as the pathological processes involve neurodegeneration and altered neurotransmission of several nondopaminergic systems that are involved in both motor and nonmotor features of the disease. This article reviews current and experimental nondopaminergic pharmacological approaches to treatments for PD with a focus on motor symptoms, treatments of L-dopa-induced motor complications and treatments of nonmotor symptoms including mood disorders, cognition, psychosis and autonomic problems.

Obsessive-compulsive symptoms among patients with blepharospasm and hemifacial spasm

OBJECTIVE

The aim of this study was to compare the prevalence and the severity of different obsessive-compulsive disorder (OCD) symptoms reported by patients with blepharospasm (BSP) with those reported by patients with hemifacial spasm (HFS). We hypothesized that, since patients with BSP present a dysfunctional striato-thalamo-cortical circuitry, they would exhibit higher prevalence and/or greater severity of OCD symptoms than patients with HFS, a condition that results from peripheral irritation of the facial nerve.

METHODS

Twenty-two patients with BSP and 31 patients with HFS were systematically evaluated by means of a sociodemographic and clinical questionnaire, the Mini International Neuropsychiatric Interview, the Obsessive-Compulsive Inventory-Revised, the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI) and the Mini Mental State Examination (MMSE). Diagnostic groups were compared using the Mann-Whitney U test for continuous variables and the Pearson's goodness-of-fit χ(2) test for categorical ones; Fisher's Exact Test was employed when indicated. Correlations between continuous variables were evaluated by means of Spearman coefficients.

RESULTS

Patients with BSP and HFS were not significantly different in terms of sociodemographic characteristics and most neuropsychiatric features. Nevertheless, while checking was associated with shorter duration of BSP (Spearman's rho=-0.54; P=.01), hoarding correlated with a longer duration of HFS (Spearman's rho=0.40; P=.04). Length of abnormal movements did not correlate with the BDI, BAI and MMSE scores.

CONCLUSIONS

The finding that the severity of different OCD symptoms did not differ between the BSP and HFS groups suggests that BSP may not interfere significantly with behavioral components of the striato-thalamo-cortical circuitry. However, the fact that OCD symptoms were found to follow different courses in distinct diagnostic groups deserves further study.

Chronic (neuropathic) corneal pain and blepharospasm: five case reports

Pain and focal dystonias have been associated with chronic pain conditions such as complex regional pain syndrome. Corneal pain, frequently known as "dry eye", may be a neuropathic pain condition with abnormalities of the nerve plexus. Here we present 5 case histories of patients with defined corneal pain (with associated neuropathic features) and objective measures of changes in the nerve plexus and associated blepharospasm. A putative relationship between pain and blepharospasm suggests potential involvement of the basal ganglia in both these conditions.

Clinical features of patients with blepharospasm: a report of 240 patients

BACKGROUND AND PURPOSE

To characterize patients with benign essential blepharospasm (BEB) by diagnosis, environmental risk factors, and family history.

METHODS

Two hundred and forty patients with BEB were evaluated through a clinical examination and questionnaire. The questionnaire reviewed personal medical history, demographic factors, risk factors for the development of blepharospasm and family history of dystonia and other neurological conditions.

RESULTS

Benign essential blepharospasm was more commonly found in women (2.8:1) and 93% of the patients were Caucasian. Fifty percent had pure BEB, 31% had BEB/Meige's syndrome, and 4% had BEB and eyelid opening apraxia (+/- Meige's syndrome). A minority of patients reported preceding photophobia (25%) or other eye conditions (22%). The majority were non-smokers, had no exposure to anti-emetic or antipsychotic agents, had a normal birth history, and had no history of head trauma. Seventy-two percent did report a stressful event immediately prior to the development of symptoms. Treatments reported included botulinum toxin (BoNT), oral medications, surgical procedures, and acupuncture. Thirty-two percent of patients reported a family history of focal dystonia, and BEB was the most commonly reported.

CONCLUSION

This study confirms previous reports of usual age, sex, caffeine and tobacco use, and family history in patients with blepharospasm. New findings include a report on occupation, lower reports of preceding eye conditions and photophobia, and higher reported stressful events. Further, this study shows a change in treatment with an increase in BoNT use and decrease in surgical procedures.

Efficacy and safety of incobotulinumtoxinA (NT 201, Xeomin) in the treatment of blepharospasm-a randomized trial

IncobotulinumtoxinA (NT 201, Xeomin) is a highly purified botulinum neurotoxin type A formulation, free from complexing proteins. A randomized, placebo-controlled, double-blind trial of efficacy and safety compared incobotulinumtoxinA (up to 50 U per eye) to placebo administered in a single treatment session to patients with blepharospasm. All patients had documented satisfactory response to 2 previous treatments with botulinum neurotoxin type A other than incobotulinumtoxinA and had Jankovic Rating Scale severity subscores ≥ 2. Patients (n = 109) were randomized in a 2:1 ratio to incobotulinumtoxinA or placebo and followed up to 20 weeks; 94% completed the study. A significant difference was observed in the primary efficacy variable (change in Jankovic Rating Scale severity subscore rated by an independent rater 6 weeks following treatment), favoring incobotulinumtoxinA by 1.0 point (95% CI [0.5-1.4]; P < .001). Functional impairment, as measured by the Blepharospasm Disability Index, improved by 0.5 points (95% CI [0.2-0.7]; P = .002) compared with placebo. There was a strong correlation between the 2 scale scores. In addition, all secondary outcome measures favored incobotulinumtoxinA. Patients rated the mean therapeutic effect of incobotulinumtoxinA significantly better than placebo (P < .001). Adverse events were reported in 70.3% of incobotulinumtoxinA patients and 58.8% of placebo patients. Eyelid ptosis (18.9% vs 5.9%), dry eye (18.9% vs 11.8%), and dry mouth (14.9% vs 2.9%) occurred most frequently. Tolerability was rated good/very good by 91.9% of incobotulinumtoxinA versus in 85.2% of placebo patients. In conclusion, incobotulinumtoxinA was well tolerated and was associated with statistically significant and clinically relevant reductions in blepharospasm severity and functional impairment.

Review and update of involuntary facial movement disorders presenting in the ophthalmological setting

We review the existing literature on the involuntary facial movement disorders-benign essential blepharospasm, apraxia of eyelid opening, hemifacial spasm, and aberrant facial nerve regeneration. The etiology of idiopathic blepharospasm, a disorder of the central nervous system, and hemifacial spasm, a condition involving the facial nerve of the peripheral nervous system, is markedly different. We discuss established methods of managing patients and highlight new approaches.

Obsessive-compulsive disorder and its related disorders: a reappraisal of obsessive-compulsive spectrum concepts

Obsessive-compulsive disorder (OCD) is a clinical syndrome whose hallmarks are excessive, anxiety-evoking thoughts and compulsive behaviors that are generally recognized as unreasonable, but which cause significant distress and impairment. When these are the exclusive symptoms, they constitute uncomplicated OCD. OCD may also occur in the context of other neuropsychiatric disorders, most commonly other anxiety and mood disorders. The question remains as to whether these combinations of disorders should be regarded as independent, cooccurring disorders or as different manifestations of an incompletely understood constellation of OCD spectrum disorders with a common etiology. Additional considerations are given here to two potential etiology-based subgroups: (i) an environmentally based group in which OCD occurs following apparent causal events such as streptococcal infections, brain injury, or atypical neuroleptic treatment; and (ii) a genomically based group in which OCD is related to chromosomal anomalies or specific genes. Considering the status of current research, the concept of OCD and OCD-related spectrum conditions seems fluid in 2010, and in need of ongoing reappraisal.

Prospective, randomized, double-blind study, comparing botulinum toxins type a botox and prosigne for blepharospasm and hemifacial spasm treatment

Botulinum toxin A (BTA) is considered an effective treatment of blepharospasm and hemifacial spasm, but there are few studies to permit a comparison of its different formulations. This prospective, randomized, double-blind study compared Prosigne, a BTA of Chinese origin, with Botox to establish safety, efficacy, and equivalence of doses between those 2 formulations in blepharospasm and hemifacial spasm treatment. Fifty-seven patients participated in this study: 21 blepharospasm (from whom 11 were treated with Botox; and 10, with Prosigne) and 36 hemifacial spasm patients (17 were treated with Botox; and 19, with Prosigne). All patients were similar in age, disease time span, number of previous shots, and time elapsed since the last BTA application. Pain and burning during the injection and the result of the treatment were similar in both groups. There were no systemic adverse events, and the local ones were observed with similar intensity and frequency for both groups. The mean effect time length was similar for both blepharospasm (11.3 weeks for both toxins) and hemifacial spasm patients (12.8 weeks for Botox and 12.9 weeks for Prosigne). In both blepharospasm groups, only the 36-Item Short-Form Health Survey emotional aspects domain showed improvement from baseline after 16 weeks. There were no differences between the 36-Item Short-Form Health Survey scores before and after the treatment of all hemifacial spasm patients. Therefore, it has been concluded that Botox and Prosigne have similar efficacy, safety, and tolerability profiles, so that a dose equivalence of 1:1 may be considered for blepharospasm and hemifacial spasm treatments.

Long-term efficacy of botulinum toxin A for treatment of blepharospasm, hemifacial spasm, and spastic entropion: a multicentre study using two drug-dose escalation indexes

PURPOSE

To investigate the long-term effectiveness and safety of botulinum neurotoxin A (BoNT-A) treatment in patients with blepharospasm (BEB), hemifacial spasm (HFS), and entropion (EN) and to use for the first time two modified indexes, 'botulin toxin escalation index-U' (BEI-U) and 'botulin toxin escalation index percentage' (BEI-%), in the dose-escalation evaluation.

METHODS

All patients in this multicentre study were followed for at least 10 years and main outcomes were clinical efficacy, duration of relief, BEI-U and BEI-%, and frequency of adverse events.

RESULTS

BEB, HFS, and EN patients received a mean BoNT-A dose with a significant inter-group difference (P<0.0005, respectively). The mean (+/-SD) effect duration was statistically different (P=0.009) among three patient groups. Regarding the BoNT-A escalation indexes, the mean (+/-SD) values of BEI-U and BEI-% were statistically different (P=0.035 and 0.047, respectively) among the three groups. In BEB patients, the BEI-% was significantly increased in younger compared with older patients (P=0.008). The most frequent adverse events were upper lid ptosis, diplopia, ecchymosis, and localized bruising.

CONCLUSIONS

This long-term multicentre study supports a high efficacy and good safety profile of BoNT-A for treatment of BEB, HFS, and EN. The BEI indexes indicate a significantly greater BoNT-A-dose escalation for BEB patients compared with HFS or EN patients and a significantly greater BEI-% in younger vsolder BEB patients. These results confirm a greater efficacy in the elderly and provide a framework for long-term studies with a more flexible and reliable evaluation of drug-dose escalation.

Meige syndrome: what's in a name?

Frequently, blepharospasm is associated with involuntary movements of the platysma, lower face and masticatory muscles. Similarly, masticatory dystonia may occur in isolation or in combination with dystonia of other cranial and cervical muscles. The non-possessive and possessive forms of Meige and Brueghel syndromes have been variably and imprecisely ascribed to various anatomical variations of craniocervical dystonia. Herein, the origin of eponymic terms as applied to craniocervical dystonia is reviewed as support for proposed elimination of these eponyms from clinical usage. Although the term "segmental craniocervical dystonia" more accurately captures the combination of blepharospasm and dystonia of other head and neck muscles, delineation of craniocervical subphenotypes is essential for etiological/genetic and treatment studies. To conclude, the clinical features, epidemiology, pathophysiology and therapeutic management of segmental craniocervical dystonia are examined with a particular focus on "blepharospasm-plus" subphenotypes.

Efficacy and safety of purified botulinum toxin type A (Dysport) for the treatment of benign essential blepharospasm: a randomized, placebo-controlled, phase II trial

The majority of studies on the effects of botulinum toxin in blepharospasm patients have been small or unblinded. Our large-scale, multicenter, randomized clinical trial on the efficacy and safety of botulinum toxin (Dysport; 40, 80, and 120 units/eye) versus placebo in bilateral benign essential blepharospasm (BEB) supported the high efficacy and good safety profile of Dysport, with improvement in functional impairment, reduced frequency and intensity of facial spasms, and fewer withdrawals through lack of efficacy in the active treatment group compared with controls. The best balance of sustained efficacy and favorable safety profile was provided by 80 units of Dysport/eye in this study.

Efficacy and safety of botulinum neurotoxin type A free of complexing proteins (NT 201) in cervical dystonia and blepharospasm

Botulinum neurotoxin type A (BTX-A) weakens voluntary muscle power and is an effective therapy for focal dystonia, including cervical dystonia (CD) and benign essential blepharospasm (BEB). Antibody formation against BTX-A may lead to failure of treatment. NT 201 (XEOMIN®) is a formulation of pure BTX-A that is free of complexing proteins and therefore may have a reduced immunogenic potential in comparison with other BTX-A preparations. In clinical trials, NT 201 was found to be effective, well-tolerated and at least noninferior to a BTX-A preparation containing complexing proteins in the treatment of CD and BEB. There were no differences between the two therapies in terms of onset of action, duration and waning of effect. Future research is aimed at evaluating the benefits of NT 201.

Head trauma in primary cranial dystonias: a multicentre case-control study

BACKGROUND

The relationship between prior trauma and primary adult-onset dystonia is not well understood. Previous uncontrolled observations and exploratory case-control studies have yielded contradictory results.

OBJECTIVE

To analyse the association between cranial dystonia and prior head trauma.

METHODS

An ad hoc multicentre case-control study was performed using a semistructured interview to collect detailed information on the history of head trauma before disease onset in five Italian tertiary referral centres for movement disorders. The presence of a history of head trauma and of post-traumatic sequelae (loss of consciousness, bone fractures, scalp/facial wounds) before disease onset was recorded from 177 patients with primary adult-onset cranial dystonia and from 217 controls with primary hemifacial spasm matched by age strata and sex. Differences between groups were assessed by Mann-Whitney U test and Fisher's exact test, and the relationship between prior head trauma and case/control status was analysed by multivariate logistic regression models.

RESULTS

No association was found between vault/maxillofacial trauma and cranial dystonia. Most reported traumas occurred several years before disease onset. None of the main post-traumatic sequelae altered the chance of developing cranial dystonia compared with patients with primary hemifacial spasm, nor did head trauma modify the age at onset of cranial dystonia.

CONCLUSIONS

These results do not support prior head trauma as a possible environmental factor modifying the risk of developing late-onset cranial dystonia. The lack of association may have pathogenetic and medical-forensic implications.

Gene-environment interactions in sporadic Parkinson's disease

Much has been learned in recent years about the genetics of familial Parkinson's disease. However, far less is known about those malfunctioning genes which contribute to the emergence and/or progression of the vast majority of cases, the 'sporadic Parkinson's disease', which is the focus of our current review. Drastic differences in the reported prevalence of Parkinson's disease in different continents and countries suggest ethnic and/or environmental-associated multigenic contributions to this disease. Numerous association studies showing variable involvement of multiple tested genes in these distinct locations support this notion. Also, variable increases in the risk of Parkinson's disease due to exposure to agricultural insecticides indicate complex gene-environment interactions, especially when genes involved in protection from oxidative stress are explored. Further consideration of the brain regions damaged in Parkinson's disease points at the age-vulnerable cholinergic-dopaminergic balance as being involved in the emergence of sporadic Parkinson's disease in general and in the exposure-induced risks in particular. More specifically, the chromosome 7 ACHE/PON1 locus emerges as a key region controlling this sensitive balance, and animal model experiments are compatible with this concept. Future progress in the understanding of the genetics of sporadic Parkinson's disease depends on globally coordinated, multileveled studies of gene-environment interactions.

Treatment of dystonia

Dystonia may be a sign or symptom, that is comprised of complex abnormal and dynamic movements of different etiologies. A specific cause is identified in approximately 28% of patients, which only occasionally results in specific treatment. In most cases, treatment is symptomatic and designed to relieve involuntary movements, improve posture and function and reduce associated pain. Therapeutic options are dictated by clinical assessment of the topography of dystonia, severity of abnormal movements, functional impairment and progression of disease and consists of pharmacological, surgical and supportive approaches. Several advances have been made in treatment with newer medications, availability of different forms of botulinum toxin and globus pallidus deep brain stimulation (DBS). For patients with childhood-onset dystonia, the majority of whom later develop generalized dystonia, oral medication is the mainstay of therapy. Recently, DBS has emerged as an effective alternative therapy. Botulinum toxin is usually the treatment of choice for those with adult-onset primary dystonia in which dystonia usually remains focal. In patients with secondary dystonia, treatment is challenging and efficacy is typically incomplete and partially limited by side effects. Despite these treatment options, many patients with dystonia experience only partial benefit and continue to suffer significant disability. Therefore, more research is needed to better understand the underlying cause and pathophysiology of dystonia and to explore newer medications and surgical techniques for its treatment.

Botulinum toxin in blepharospasm and oromandibular dystonia: comparing different botulinum toxin preparations

Amongst all regions of the body, the craniocervical region is the one most frequently affected by dystonia. Whilst blepharospasm--involuntary bilateral eye closure--is produced by spasmodic contractions of the orbicularis oculi muscles, oromandibular dystonia may cause jaw closure with trismus and bruxism, or involuntary jaw opening or deviation, interfering with speaking and chewing. Both forms of dystonia can be effectively treated with botulinum toxin injection. This article summarizes injection techniques in both forms of dystonia and compares doses, potency and efficacy of different commercially available toxins, including Botox, Dysport, Xeomin and Myobloc/NeuroBloc.

Benign Essential Blepharospasm: Risk Factors with Reference to Hemifacial Spasm

BACKGROUND

To identify risk factors associated with benign essential blepharospasm (BEB) with reference to hemifacial spasm (HFS). Persons with BEB and HFS experience similar physical symptoms, yet the two disorders have different etiologies.

METHODS

Patients with BEB (n = 159) or HFS (n = 91) were identified from two large neuro-ophthalmology clinics. Demographic, medical, behavioral, and psychological characteristics were obtained from chart review and a telephonic survey questionnaire.

RESULTS

The average age of BEB and HFS was 66 years. Most patients in both groups were retired, white, and female. BEB patients were more than two times as likely to meet the diagnostic criteria for generalized anxiety disorder than HFS patients (odds ratio, 2.13; 95% confidence interval, 1.22-3.72). There was no difference between the two groups regarding demographics, smoking, a family history of dystonia, Parkinson disease, Bell palsy, Tourette disorder, obsessive compulsive symptoms, history of head trauma, alcohol use, or caffeine consumption.

CONCLUSIONS

As compared to HFS, BEB was significantly more often associated with generalized anxiety disorder. Given the similarity of other clinical features of these two disorders, it is reasonable to conclude that anxiety is a cause not a consequence of BEB. Contrary to previous studies, BEB was not associated with obsessive-compulsive symptoms, head trauma, Parkinson disease, Bell palsy, Tourette disorder, or lack of smoking.

Modulation of sensory photophobia in essential blepharospasm with chromatic lenses

PURPOSE

To determine the effect of photochromatic modulation with tinted lenses on the sensory symptoms of photophobia in blepharospasm patients.

DESIGN

Nonrandomized case-control study.

PARTICIPANTS

Thirty-four subjects (24 benign essential blepharospasm patients and 10 normal controls).

METHODS

Subjects were seated in front of a calibrated light source. Beginning at 0%, the intensity of the light source was increased gradually until the patient reported symptomatic photophobia. The intensity of the light source was then measured with a light meter. This procedure was performed first with no chromatic lens and then with 7 different chromatic lenses, each blocking specific wavelengths of the visible spectrum. The subject was then asked which lens provided the greatest symptomatic improvement of photophobia. Statistical significance was calculated with analysis of variance and t test analysis.

MAIN OUTCOME MEASURES

Objective measurement of light intensity tolerated and subjective assessment of photophobia were obtained for each chromatic lens tested.

RESULTS

The light intensity tolerated by the normal subjects compared with the blepharospasm group was not statistically significant with no lens, but grew to 3.5 times that tolerated by the blepharospasm group as more of the higher wavelengths of the visible spectrum were blocked (P = 0.048). Lenses 4, 5, 6, and 7 allowed blepharospasm patients to tolerate a significantly higher intensity of light when compared with no lens (P = 0.04, P = 0.007, P = 0.03, and P = 0.01, respectively). Although the highest intensity of light tolerated was measured with lens 6, 71% of blepharospasm patients reported the greatest relief of photophobia with lens 7.

CONCLUSIONS

Blepharospasm patients tolerate a lower intensity of light when compared with normal subjects; this differential in light tolerance becomes significantly more pronounced as the higher wavelengths of the visible spectrum are blocked. The symptoms of photophobia in blepharospasm patients can be reduced significantly with photochromatic modulation. Despite lens 6 allowing the patients to tolerate a higher intensity of light, the majority of patients preferred lens 7 for symptomatic relief of photophobia. These findings suggest that sensory photophobia may be related more to the wavelength than to the intensity of the light exposure.

Relationship between eye symptoms and blepharospasm: A multicenter case–control study

Although patients with primary blepharospasm (BSP) commonly report experiencing ocular symptoms before the onset of orbicular spasms, the precise frequency and pathogenic role of this subjective ocular discomfort are poorly understood. We conducted a multicenter case-control study to investigate symptoms related to disorders of the anterior segment of the eye, administering a questionnaire to 165 patients with BSP and 180 age- and gender-matched control patients with hemifacial spasm. On a validation sample, our questionnaire yielded high accuracy in detecting eye diseases (predominantly, dry eye syndrome) using detailed ophthalmological examination as the criterion. Logistic regression analysis indicated a significant association between ocular symptoms at disease onset and BSP. Ocular symptoms starting in the year preceding disease onset (short-latency symptoms) showed a stronger association with BSP than ocular symptoms occurring earlier in time (long-latency symptoms). The association was stronger when short-latency symptoms developed from 40 to 59 years of age, whereas this was not observed for long-latency symptoms. Our findings support the view that eye symptoms associated with BSP result from eye diseases and may be involved in the pathogenesis of BSP. The differential risk of developing BSP, based on age at onset of ocular symptoms, suggests that age and eye diseases may interact in giving rise to BSP.

Development of Parkinson's disease in patients with blepharospasm

The liability to develop parkinsonian symptoms was evaluated in 105 outpatients with idiopathic blepharospasm (IBS; 54 cases) or IBS associated to oromandibular dystonia (Meige's syndrome; 51 cases) mean age 70.3 +/- 9.6 years, and compared with an age- and sex-matched population. Eleven patients developed Parkinson's disease in the blepharospasm group, whereas only 2 of 105 patients were affected in the control group. Our results suggest that patients with IBS either isolated or associated with oromandibular dystonia are more prone to develop parkinsonian symptoms.

Prevalence of primary late-onset focal dystonia in the Belgrade population

The aim of this cross-sectional study was to estimate the prevalence of different subtypes of idiopathic focal dystonia in the population of Belgrade (Serbia), Yugoslavia. On December 31, 2001, the crude prevalence of all studied types of dystonia (focal, segmental, and multifocal) in Belgrade was 13.6 per 100,000 population (11.8 per 100,000 for men and 15.2 per 100,000 for women). Type-specific prevalence for focal dystonia was 11.2 per 100,000. The prevalence for cervical dystonia, blepharospasm, writer's cramp and laryngeal dystonia were 5.9 per 100,000, 1.9 per 100,000, 1.9 per 100,000, and 1.1 per 100,000, respectively.