Surgical correction of intractable blepharospasm. Technical improvements

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.

Surgical management of essential blepharospasm

We have reviewed the surgical management of essential blepharospasm over the last 15 years, comparing the results from facial nerve avulsion with those from orbicularis muscle stripping. After facial nerve avulsion 50% of patients remained free of troublesome spasm for 15 months after surgery, but only 25% remained so for more than two years. Following orbicularis oculi myectomy 50% of patients were free of troublesome spasms for 30 months after surgery and 55% of patients had relief from spasm for more than two years. Secondary effects of the two procedures are compared and are found to be fewer after orbicularis myectomy. There were no major complications after either form of surgery. Botulinum toxin is the treatment of first choice for this condition. If this becomes ineffective or inconvenient, surgical treatment is warranted and should not be deferred for fear of severe side effects of treatment, since these are rare. Protractor myectomy gives longer relief from blepharospasm than facial nerve avulsion and has fewer complications. However, it is technically difficult, time consuming, and has greater peroperative morbidity. Facial nerve avulsion may therefore still have a role in selected patients.

Essential blepharospasm and related dystonias

Essential blepharospasm is an idiopathic disorder of progressive involuntary spasms of the orbicularis oculi and upper facial (corrugator, procerus) muscles. Blepharospasm literally means spasm of the eyelids; however, most patients with blepharospasm also have or will develop squeezing in the lower face and neck muscles (Meige's syndrome, orofacial dystonia, or oromandibular dystonia). Some patients develop dystonic, uncontrolled movements in areas outside the facial nerve distribution (segmental cranial dystonia or craniocervical dystonia). Chronic, forceful squeezing by the periocular muscles becomes debilitating for the patient and leads to functional and cosmetic eyelid deformities. Treatment has included a variety of modalities and oral medications that are of limited efficacy. Botulinum-A toxin injections have delivered the best temporary relief from this disorder, while the periorbital myectomy operation has been shown to give the best long-term results.

Botulinum toxin for benign essential blepharospasm, hemifacial spasm and age-related lower eyelid entropion

Purified botulinum A exotoxin was used in the treatment of forty seven patients with benign essential blepharospasm, 11 patients with hemifacial spasm and 2 patients with age-related entropion. The treatment was effective in all three groups for an average of 3-4 months when symptoms recurred and repeated chemodenervation with toxin was needed. The commonest complication was transient ptosis with an overall frequency of 7.8%. This incidence increased to 11.1% with toxin doses higher than 25 units per orbicularis. The treatment was well accepted by the patients, who were subsequently able to return to pre-blepharospasm lifestyles.

Treatment of facial spasm with Oculinum (C. botulinum toxin)

Forty-six consecutive adult patients with facial spasm were treated with one or more Botulinum toxin (Oculinum) injections to control muscle spasm. During the follow-up period of 6.6 months (one week-12 months), 27 patients required retreatment with a mean time interval of 3.4 months between treatments. Control of facial spasm was achieved in all patients. Complications included occasional bruising around the injection site and a transient blepharoptosis in one patient. No systemic effect was observed. This preliminary report suggests that treatment with Botulinum toxin (Oculinum) is an acceptable alternative to surgical management in select patients.

The use of botulinum toxin in the medical management of benign essential blepharospasm

Twenty-eight patients with mild or moderate cases of benign essential blepharospasm were treated with botulinum toxin Type A. Average follow-up was six months. The injection technique used on these patients is illustrated. The treatment was effective in virtually all patients treated, although transient; the mean interval of relief of spasm was approximately two and one-half months. Potential side effects include ptosis and epiphora. Botulinum toxin as an initial treatment or as an adjunct in postsurgical residual blepharospasm shows promise in this preliminary study.

Parotid duct injury as a complication of differential seventh nerve ablation

A 68-year-old man with intermittent blepharospasm complained of pain and induration after undergoing differential ablation of the seventh nerve. Because radiation therapy was ineffective, we inserted a 5-mm silicone tube into a serous cyst in the parotid gland. The induration subsided and the patient's recovery was uneventful.