Regional differences in the orbicularis oculi muscle: conservation between species

Debunking the Puzzle of Eyelid Apraxia: The Muscle of Riolan Hypothesis

PURPOSE

Apraxia of eyelid opening (AEO) has been defined by the presence of an intermittent nonparalytic bilateral loss of the volitional ability to open the eyes or to maintain the eyelids in a sustained elevated position. It is not known whether the condition represents an apraxia, a dystonia, or a freezing phenomenon, and several different nomenclatorial terms have been suggested for this condition including the so-called AEO (scAEO), blepahrocolysis, focal eyelid dystonia, and so on. The primary goal of this review is to attempt to clarify the pathogenetic mechanisms underlying scAEO as a clinical phenomenon. This review also addresses the issue of whether scAEO is part of the spectrum of blepharospasm (BSP) which includes BSP, dystonic blinks and other dystonic eyelid conditions, or whether it is a separate phenomenologically heterogeneous disease with clinical features that merely overlap with BSP.

METHODS

A literature review was conducted in PubMed, MEDLINE, PubMed Central (PMC), NCBI Bookshelf, and Embase for several related keywords including the terms "apraxia of eyelid opening," "pretarsal blepharospasm," "blepharocolysis," "eyelid freezing," "eyelid akinesia," "levator inhibition," "blepharospasm-plus," as well as "blepharospasm." The clinical findings in patients with scAEO who fulfilled the classic diagnostic criteria of the disease that were originally set by Lepore and Duvoisin were included, while patients with isolated blepharospasm or dystonic blinks (DB) were excluded. In addition, electromyographic (EMG) studies in patients with scAEO were reviewed in detail with special emphasis on studies that performed synchronous EMG recordings both from the levator muscle (LPS) and the pretarsal orbicularis oculi muscle (OO).

RESULTS

The apraxia designation is clearly a misnomer. Although scAEO behaves clinically as a hypotonic freezing phenomenon, it also shares several cardinal features with focal dystonias. The authors broadly categorized the EMG data into 3 different patterns. The first pattern (n = 26/94 [27.6%]) was predominantly associated with involuntary discharges in the OO muscle and has been termed pretarsal blepharospasm (ptBSP). The commonest pattern was pattern no. 2 (n = 53/94 [56.38%]), which was characterized by involuntary discharges in the OO muscle, together with a disturbed reciprocal innervation of the antagonist levator muscle and is dubbed disturbed reciprocal innervation (DRI). This EMG pattern is difficult to discern from the first pattern. Pattern no. 3 (n = 15/94 [15.9%]) is characterized by an isolated levator palpebrae inhibition (ILPI). This levator silence was observed alone without EMG evidence of contractions in the pretarsal orbicularis or a disturbed reciprocal relation of both muscles.

CONCLUSION

EMG evidence shows that the great majority (84%) of patients show a dystonic pattern, whereas ILPI (16%) does not fit the dystonic spectrum. The authors propose that a spasmodic contraction of the muscle of Riolan may be the etiological basis for levator inhibition in patients with ILPI. If this is true, all the 3 EMG patterns observed in scAEO patients (ptBSP, DRI, and ILPI) would represent an atypical form of BSP. The authors suggest coining the terms Riolan muscle BSP ( rmBSP ) for ILPI, and the term atypical focal eyelid dystonia ( AFED ) instead of the term scAEO, as both terms holistically encompass both the clinical and EMG data and concur with the authors' theorem.

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.

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.

The facial motor system

Facial movements support a variety of functions in human behavior. They participate in automatic somatic and visceral motor programs, they are essential in producing communicative displays of affective states and they are also subject to voluntary control. The multiplicity of functions of facial muscles, compared to limb muscles, is reflected in the heterogeneity of their anatomical and histological characteristics that goes well beyond the conventional classification in single facial muscles. Such parcellation in different functional muscular units is maintained throughout the central representation of facial movements from the brainstem up to the neocortex. Facial movements peculiarly lack a conventional proprioceptive feedback system, which is only in part vicariated by cutaneous or auditory afferents. Facial motor activity is the main marker of endogenous affective states and of the affective valence of external stimuli. At the cortical level, a complex network of specialized motor areas supports voluntary facial movements and, differently from upper limb movements, in such network there does not seem to be a prime actor in the primary motor cortex.

Surgical anatomy of the upper eyelid relating to upper blepharoplasty or blepharoptosis surgery

Eyelid anatomy, including thickness measurements, was examined in numerous age groups. The thickest part of the upper eyelid is just below the eyebrow (1.127±238 µm), and the thinnest near the ciliary margin (320±49 µm). The thickness of skin at 7 mm above the eyelashes was 860±305 µm. The results revealed no significant differences among the age groups. Fast fibers (87.8±3.7%) occupied a significantly larger portion of the orbicularis oculi muscle (OOM) than nonfast fibers (12.2±3.7%). The frontalis muscle passed through and was inserted into the bundles of the OOM on the superior border of the eyebrow at the middle and medial portions of the upper eyelid. Laterally, the frontalis muscle inserted about 0.5 cm below the superior border of the eyebrow. Fast fibers occupied a significantly larger portion of the OOM than did non-fast fibers. The oculomotor nerve ends that extend forward to the distal third of the levator muscle are exposed and vulnerable to local anesthetics and may be numbed during blepharoplasty. The orbital septum consists of 2 layers. The outer layer of loose connective tissue descends to interdigitate with the levator aponeurosis and disperses inferiorly. The inner layer follows the outer layer, then reflects and continues posteriorly with the levator sheath. Widths of the tarsal plate at its lower border, mid-height, and upper border were 21.8±1.8, 16.2±1.6, and 8.3±1.0 mm, respectively. The widths of the levator aponeurosis were 32.0±2.2, 29.2±3.5, and 27.2±3.9 mm, respectively. Below the levator, the "conjoint fascial sheath" (CFS) is attached to the conjunctival fornix. The CFS was 12.2±2.0 mm anteroposterior length and 1.1±0.1 mm thick. The shape was equilateral trapezoid with a longer base anteriorly. The superior palpebral muscle was trapezoidal. The lengths of its sides were 15.58±1.82 and 22.30±5.25 mm, and its height was 13.70±2.74 mm. The width of the levator aponeurosis was approximately 4 mm wider than the superior palpebral muscle.

The dazzle reflex: electrophysiological signals from ocular muscles reveal strong binocular summation effects

Under dark adapted or dim conditions the mammalian visual system is carefully programmed to respond rapidly to the sudden onset of bright lights. This response, called the dazzle reflex, is controlled from sub-cortical structures of the brain. It is known anecdotally that exposure to a bright light when dark adapted induces an instinctive closure of one eye to reduce the pain associated with dazzle. This binocular summation of the dazzle response has not previously been reported. The dazzle reflex can be measured in human subjects by recording the electrical activity from surface electrodes located near the muscles around the eye. In this paper we report an investigation of the apparent binocular summation of the dazzle reflex using this technique. The data reveal a clear difference between monocular and binocular stimulation, with the binocular response being much larger than the monocular response. Furthermore this monocular/binocular difference arises only if the stimulus duration is longer than approximately 1 s. These observations are interpreted in terms of the known physiology of blink mechanisms.

Gradient of adaptability in four different motor systems performing the same learned motor task in cats

The ability of four different brainstem motoneuron pools to perform a newly acquired motor task was studied in alert cats. A classical conditioning of eyelid responses was carried out in (i). unoperated animals, and in animals with (ii). transection, 180 degrees rotation, and re-suture of the zygomatic facial nerve branch, (iii). a crossed anastomosis of the buccal to the zygomatic facial nerve branch and (iv). a hypoglossal-facial nerve anastomosis. Animals were conditioned with a delay paradigm using a tone (350 ms, 600 Hz, 90 dB) as conditioned stimulus, followed 250 ms later by an air puff (100 ms, 3 kg/cm2) as unconditioned stimulus. Animals with zygomatic nerve rotation performed conditioned responses (CRs) at control rate, with significantly larger amplitude, area and velocity, but a de-synchronized oscillatory pattern. Animals with buccal-zygomatic anastomosis acquired CRs at control rate, but these CRs had significantly smaller amplitude than those of controls and a de-synchronized pattern. Animals with a hypoglossal-facial anastomosis were unable to perform CRs. The trigeminal hyper-reflexia triggered by the axotomy was probably the origin of the large CRs after zygomatic nerve rotation. Trigeminal hyper-reflexia could also contribute to generation of the small CRs recorded after buccal-zygomatic anastomosis. Although trigeminal hyper-reflexia was also present following hypoglossal-facial anastomosis, hypoglossal motoneurons did not reach their firing threshold to perform CRs. In accordance with the embryonic origin of involved motoneurons, animals with buccal-zygomatic and hypoglossal-facial anastomoses moved the ipsilateral eyelid synchronously to mouth-related activities. It is suggested that there is a gradient of adaptability in motoneuron pools forced to perform new motor tasks through foreign muscles, which depends on their embryological origins and functional properties.

Motoneuron adaptability to new motor tasks following two types of facial-facial anastomosis in cats

The ability of the facial motor system to adapt to a new motor function was studied in alert cats after unilateral transection, 180 degrees rotation and suture of the zygomatic nerve, or transection and cross-anastomosis of the proximal stump of the buccal nerve to the distal stump of the zygomatic nerve. These procedures induced reinnervation of the orbicularis oculi (OO) muscle by different OO- or mouth-related facial motoneurons. Eyelid movements and the electromyographic activity of the OO muscle were recorded up to 1 year following the two types of anastomosis. Animals with a zygomatic nerve rotation recovered spontaneous and reflex responses, but with evident deficits in eyelid kinematics, i.e. the proper regional distribution of OO motor units was disorganized by zygomatic nerve rotation and resuture, producing a permanent defect in eyelid motor performance. Following buccal-zygomatic anastomosis, the electrical activity of the OO muscle was recovered after 6-7 weeks, but air puff-, flash- and tone-evoked reflex blinks never reached the control values on the operated side. Electromyographic OO activities and lid movements corresponding to licking and deglutition activities were observed on the operated side in buccal-zygomatic anastomosed animals up to 1 year following surgery. Mouth-related facial motoneurons did not readapt their discharges to the kinetic, timing and oscillatory properties of OO muscle fibres. A significant hyper-reflexia was observed following both types of nerve repair in response to air puffs, but not to light flashes or tones. In conclusion, adult mammal facial premotor circuits maintain their motor programmes when motoneurons are induced to reinnervate a foreign muscle, or even a new set of muscle fibres.

Effect of hyperthyroidism on the orbicularis oculi muscle in rabbits

PURPOSE

To determine the effect of hyperthyroidism on both myofiber number and myosin heavy-chain isoform composition within the palpebral orbicularis oculi muscle in rabbits.

METHODS

Four New Zealand White rabbits were made hyperthyroid by injection of 3,3,3'-triiodothyroinine intraperitoneally every other day for 1 month. Four rabbits were used as control animals. After 1 month the rabbits were euthanized, and the eyelids were excised and sectioned in a cryostat. The sections were immunostained to determine the presence of fast, slow, and neonatal myosin heavy-chain isoforms. To determine alterations in myofiber number, differential counts of myofiber number and the cross-sectional areas of the muscle fibers were performed with the use of computerized morphometry.

RESULTS

The orbicularis oculi muscle in the palpebral portion of the eyelids from hyperthyroid rabbits had significantly fewer myofibers compared with control eyelids, predominantly as the result of a loss of myofibers in the preseptal region. The remaining fibers showed continued expression of fast myosin but upregulated coexpression of slow myosin isoform.

CONCLUSIONS

Hyperthyroidism led to reduced orbicularis oculi muscle in the rabbit model and an alteration in the myosin heavy-chain isoform composition. This finding may help explain the clinical finding of eyelid retraction in patients with Graves orbitopathy.

Conditioned eyeblink response consists of two distinct components

The aim of these experiments was to obtain a detailed knowledge of how the orbicularis oculi muscle is activated during the execution of a conditioned eyeblink response (CR). This is the first critical step to understand the underlying neural mechanisms involved in the control of the CR. Decerebrate ferrets were trained in a classical conditioning paradigm. The conditioned stimulus (CS) was a train of electrical stimuli (15 pulses, 50 Hz, 1 mA) applied to the forelimb, and the unconditioned stimulus (US) was a train of electrical stimuli (3 pulses, 50 Hz, 3-4 mA) to the periorbital region. The CRs were studied by recording electromyograms (EMGs) from the orbicularis oculi muscle. The eyeblink CR in all animals showed a similar topography with at least two different components, CR1 and CR2, which were expressed at different rates. CR1 appeared first during acquisition, had a shorter onset latency, and was more phasic and more resistant to extinction than CR2. A marked pause in the muscle activity separated the two components. To control that the two-component CR were not species, paradigm or preparation specific, awake rabbits were trained with a tone CS (300 ms, 4 kHz, 64 dB) and a train of periorbital stimuli as US (3 pulses, 50 Hz, 3 mA). CR1 and CR2 were present in the rabbit eyeblink CR. The cerebellum is implicated in the control of CRs and to study whether separate neural pathways were responsible for CR1 and CR2, direct brachium pontis stimulation was used to replace the forelimb CS. CR1 and CR2 were present in the CR elicited by the brachium pontis CS. The presence of CR1 and CR2 after a unilateral lesion of the brachium conjunctivum shows that output from the contralateral cerebellar hemisphere was not the cause for any of the components. Other mechanisms that might be involved in the separation of the CR into two components are discussed. The results show that the eyeblink CR consists of at least two components, CR1 and CR2, which most likely originate either as a direct central command from the cerebellum or in the output pathway before the facial nucleus.

Contractile activation characteristics of single permeabilized fibres from levator palpebrae superioris, orbicularis oculi and vastus lateralis muscles from humans

1. We investigated the contractile activation characteristics of single membrane-permeabilized fibres from the following muscles from humans: the levator palpebrae superioris (LPS), an extraocular muscle; the orbicularis oculi (OO), a facial muscle; and the vastus lateralis (VL), a major muscle of the thigh. 2. Single permeabilized muscle fibres were isolated from each of the different muscles, attached to a sensitive force transducer and activated by rapid immersion in buffered solutions of varying [Ca2+] and [Sr2+]. Fibres were allocated into discrete populations based on their contractile characteristics, including their differential force responses during Ca2+ and Sr2+ activation. 3. With the exception of one fibre from the LPS, all 152 fibres sampled from the three different human muscles could be classified into either population I (slow, type I) or population II (fast, type II) based on their force-pCa(pSr) relations. The LPS muscle fibre which was unable to be classified into the two major fibre populations displayed a combination of the typical force-pCa(pSr) relations for mammalian fast and slow muscle fibres. 4. Although fibres from the LPS, OO and VL muscles had similar differential sensitivities to Ca2+and Sr2+, the steepness of the force-pCa(pSr) curves for fibres from the LPS and OO muscles were highly variable compared with those for fibres from the VL muscle. Specific forces (N cm-2) of the smaller diameter fibres from the LPS and OO muscles were significantly lower than those of fibres from the VL muscle. 5. The differences in the contractile activation characteristics between fibres from the VL muscle and those of fibres from facial (OO) muscles and extraocular (LPS) muscles, reflect the differences in their fibre composition that are responsible for their functional specificity.

Role of proprioception in the control of lid position during reflex and conditioned blink responses in the alert behaving cat

The contribution of the orbicularis oculi muscle to the determination of lid position, and the putative role of eyelid proprioception in the control of reflex and conditioned eye blinks, were studied in alert behaving cats. Upper lid movements and the electromyographic activity of the orbicularis oculi muscle were recorded during reflexively evoked blinks and during the classical conditioning of the eyelid response. Blinks were evoked by air puffs, flashes and electrical stimulation of the supraorbitary branch of the trigeminal nerve. Eyelid responses were conditioned with a trace classical conditioning paradigm consisting of a short, weak air puff, followed 250 ms later by a long, strong air puff. Orbicularis oculi muscle activation during reflex blinks was independent of lid position and was not modified by the presence of weights acting in the upward or downward directions. Local anesthesia of the supraorbital nerve reduced blinks evoked by air puffs applied to the lower jaw, but did not affect flash-evoked blinks. No relationship was established between initial lid position and the first downward component of conditioned eyelid responses. In contrast, initial lid position was related to the first upward component of the same conditioned response. It is concluded that orbicularis oculi motor units receive no feedback proprioceptive signals from the eyelid, other than those coming from cutaneous receptors, and that lid position is determined by the activity of the levator palpebrae superioris muscle. The lack of sensory information about lid position in facial motoneurons probably has some functional implications on the central control of cognitive and emotional facial expressions.

Muscle fiber type compartmentalization and expression of an immature myosin isoform in the sternocleidomastoid muscle of rabbits and primates

The sternocleidomastoid muscle is located in the neck and is both a neck rotator and flexor. Cervical dystonia, a focal dystonia disorder, is characterized by forceful involuntary contraction of a group of neck muscles, usually including the sternocleidomastoid. Little is known about the fiber type composition, fiber type compartmentalization and innervation patterns in this muscle in rabbit and primates. Sternocleidomastoid muscles from rabbit and monkey were analyzed for muscle fiber type composition and number, muscle fiber cross-sectional area and patterns of innervation. The sternocleidomastoid muscle was composed of two distinct regions, or compartments, with different fiber type compositions: an outer or superficial region composed of mostly type 2 myofibers and an inner deep region composed of both type 2 and type 1 myofibers. Neonatal myosin heavy chain isoform was detected in approximately 25% of the myofibers in both regions of the muscle. Neuromuscular junctions were located in seven endplate bands approximately 1-3 cm apart throughout the length of the muscle. There is clear evidence of anatomical subdivisions within this muscle. Not only is there variation in fiber type composition between superficial and deep regions of the muscle, but unlike most other mature skeletal muscles, it continues to express neonatal myosin heavy chain isoform in the adult. The motor program for neck movements is extremely complex, and the histological complexity plays a role in allowing for a continuum of movements of the head and neck, from maintenance of posture to rapid head movements.

Quantal organization of reflex and conditioned eyelid responses

Quantal organization of reflex and conditioned eyelid responses. J. Neurophysiol. 78: 2518-2530, 1997. Upper lid movements and the electromyographic activity of the orbicularis oculi muscle were recorded in behaving cats during spontaneous and experimentally evoked reflex blinks, and conditioned eyelid responses. Reflex blinks evoked by the presentation of air puffs, flashes, or tones consisted of a fast downward lid movement followed by late, small downward waves, recurring at approximately 50-ms intervals. The latency, maximum amplitude, peak velocity, and number of late waves depended on the modality, intensity, and duration of the evoking stimulus. The power spectra of acceleration records indicated a dominant frequency of approximately 20 Hz for air puff-evoked blinks. Flashes and tones usually evoked small and easily fatigable reflex responses of lower dominant frequencies (14-17 and 9-11 Hz, respectively). A basic approximately 20-Hz oscillation was also noticed during lid fixation, and ramplike lid displacements evoked by optokinetic stimuli. Five classical conditioning paradigms were used to analyze the frequency-domain properties of conditioned eyelid responses. These learned lid movements differed in latency, maximum amplitude, and profile smoothness depending on the modality (air puff, tone), intensity (weak, strong), and presentation site (ipsi-, contralateral to the unconditioned stimulus) of the conditioned stimulus. It was found that the characteristic ramplike profile of a conditioned response was not smooth, but appeared to be formed by a succession of small waves at a dominant frequency of approximately 20 Hz. The amplitude (and number) of the constituting waves depended on the characteristics of the conditioned stimulus and on the time interval until unconditioned stimulus presentation. Thus conditioned responses seemed to be formed from lid displacements of 2-6 degrees in amplitude and approximately 50 ms in duration, which increased in number throughout conditioning sessions, until a complete (i.e., lid closing) conditioned response was reached. It is suggested that a approximately 20-Hz oscillator underlies the generation of reflex and conditioned eyelid responses. The oscillator is susceptible to being neurally modulated to modify the velocity of a given quantum of movement, and the total duration of the lid response. Learned eyelid movements are probably the result of a successively longer release of the oscillator as a function of the temporal-spatial needs of the motor response.

Doxorubicin chemomyectomy in orbicularis oculi: increasing drug infiltration at the injection site

PURPOSE

Doxorubicin is an effective agent for chemomyectomy of the orbicularis oculi muscle when injected directly into the eyelid. However, the amount of muscle loss often differs throughout the medial to lateral extent of the eyelid. In order to increase uniform muscle loss in rabbit eyelids, doxorubicin was injected together with agents known to increase the spread of drugs at their injection site in an attempt to increase infiltration of the doxorubicin in the plane of the orbicularis oculi muscle.

METHODS

Three agents were injected, singly or in combination, 20 min prior to doxorubicin administration. Drugs included: collagenase, hyaluronidase, bupivacaine, and hyaluronidase and bupivacaine together. Doxorubicin was injected at a dose of either 0.5 mg, 1 mg or 2 mg. Muscle loss from the co-treatments was compared with that seen with doxorubicin alone as assessed by light microscopic morphometric analysis of the treated eyelids one month after treatment.

RESULTS

Injection of doxorubicin alone resulted in a dose-related muscle loss. Injections of either collagenase or hyaluronidase prior to doxorubicin treatment did not alter muscle loss compared with doxorubicin alone. The combination of hyaluronidase and bupivacaine slightly increased muscle loss over doxorubicin alone at the lower doses of doxorubicin. Muscle loss was increased further after doubling the dose of hyaluronidase. Collagenase pretreatment exacerbated eyelid skin injury. Hyaluronidase did not influence the skin toxicity of doxorubicin at doses of 1 or 2 mg, but did result in a delayed onset and a shorter duration of skin injury at the 0.5 mg dose of doxorubicin.

CONCLUSIONS

Only hyaluronidase combined with bupivacaine increased doxorubicin induced myotoxicity in the orbicularis oculi muscle, presumably by increasing doxorubicin infiltration at the intramuscular injection site throughout the length of the muscle fibers. Thus, the combined injection of hyaluronidase and bupivacaine prior to doxorubicin treatment improves doxorubicin chemomyectomy by increasing drug infiltration throughout the full extent of the orbicularis oculi muscle. Future studies will be directed at achieving better penetration of the drug into individual muscle cells.

Injection of doxorubicin into rabbit eyelid does not result in loss of facial motor neurons

In both laboratory and clinical studies, injection of doxorubicin directly into the eyelid results in permanent muscle loss of the majority of fibers within treated eyelids. A first clinical trial of this technique in blepharospasm and hemifacial spasm patients has been performed. All patients who completed a full course of doxorubicin treatment showed a permanent decrease in eyelid strength, with over 50% of these patients requiring no further treatment. Doxorubicin is known to be carried by retrograde axonal transport to the brain and is a known neurotoxin. This raises the question of the effect of these treatments on the facial neurons which innervate the orbicularis oculi muscle in the eyelids. The effect on the number of facial neurons present after injection of doxorubicin into the eyelid of rabbits was determined using both HRP and diI retrograde labeling techniques. Despite the extensive and permanent muscle loss caused by the doxorubicin treatments, there was no measurable loss of facial neurons on the doxorubicin treated sides. DiI was shown to be myotoxic at high concentrations and amplified the myotoxic effect of doxorubicin. Lack of neuronal loss may offer assurance of clinical safety to the facial motor neurons of muscle spasm patients who receive doxorubicin injections into their eyelids.

Botulinum toxin paralysis of the orbicularis oculi muscle. Types and time course of alterations in muscle structure, physiology and lid kinematics

In chronically prepared guinea pigs, we investigated the time course of botulinum toxin A's (Bot A) effect on the blink reflex by monitoring lid movements and EMG activity prior to and after Bot A injection into the orbicularis oculi muscle (OOemg), or after nerve crush of the zygomatic nerve. We correlated these alterations with the morphological changes of the orbicularis oculi (lid-closing) muscles of the same animals. After Bot A treatment there was a profound reduction of OOemg activity and blink amplitudes as well as a slowing of maximum blink down-phase velocity. Blink up-phases, however, remained unchanged. Gradual recovery of OOemg magnitude and blink amplitude started around day 6; a functioning blink reflex appeared on day 21, and full recovery of blink amplitude occurred by day 42. Crushing the zygomatic branch of the facial nerve produced similar changes in blink parameters, but recovery was much more rapid (15 days) than for Bot A-treated guinea pigs. The morphological analysis demonstrated that Bot A produced a denervation-like atrophy in the orbicularis oculi. No fiber type-specific alterations were noted, and all muscle fiber types ultimately recovered, with no longstanding consequences of the transient denervation. Our findings support the notion that functional recovery was the result of preterminal and terminal axonal sprouting that subsequently re-established functional innervation. Moreover, differences between the present findings and those seen after injection of Bot A into the extraocular muscles strongly support the hypothesis that the composition in terms of muscle fiber type and the properties of the motor control system of a given muscle greatly influence both how the particular muscle responds to toxin injection, and how effective the toxin is in resolution of neuromuscular disorders that affect a particular muscle. The present findings were consistent with clinical observations that Bot A produces only temporary relief in patients with essential blepharospasm. It is likely that the efficacy of Bot A in treatment of blepharospasm could be improved by using agents that suppress terminal sprouting. The close correspondence of the changes in blink physiology between human patients and guinea pigs after Bot A treatment demonstrate that the guinea pig is an excellent model system for testing strategies to prolong the beneficial effects of Bot A treatment in relieving lid spasms in human subjects.

Acute morphologic changes in orbicularis oculi muscle after doxorubicin injection into the eyelid

This study attempts to gain a better understanding of the primary cause of doxorubicin myotoxicity to aid in the development of a protocol to increase its effectiveness in treating muscle spasm diseases. The time course of acute injury to the orbicularis oculi muscle after injection of doxorubicin into the eyelids of rabbits was examined. The effects of doxorubicin injection were immediate and dramatic. Within 5 minutes, the muscle cells in the eyelids showed signs of myofibrillar dissolution. This process continued for the first 24 hours, with a marked decrease in the total number of myofibers by 1 hour after drug treatment. By 4 days after doxorubicin injection, most of the treated muscle had a more normal morphology, although some ongoing myofibrillar dissolution was present. There was evidence for a limited amount of muscle regeneration. Three levels of injury were seen: a severe, irreversible injury in the majority of the myofibers; a mild, reversible injury in a subset of the fibers; and a group of myofibers apparently uninjured as a result of doxorubicin treatment. Doxorubicin toxicity in skeletal muscle is of rapid onset. Understanding the primary cause and acute changes in doxorubicin myotoxicity may accelerate the development of improved protocols to increase the effectiveness of doxorubicin in treating muscle spasm diseases.

Surface electromyographic study of idiopathic cranial dystonia focused on the orbicularis oculi muscles

We studied 115 Japanese patients with idiopathic cranial dystonia (Meige disease), using surface electromyography (EMG) focused on the orbicularis oculi muscles to classify the findings of the abnormal involuntary movements of this disease and to evaluate the pathophysiology of blepharospasm (BS). Surface EMGs at rest and at voluntary eyelid opening after eyelid closing were investigated. We found 62 (53.9%) patients exhibiting the overblinking type, 37 (32.2%) the tonic BS type, and 16 (13.9%) the normal type of behavior, considering the frequency of spontaneous blinking and presence of spasms. The present results suggest that BS is not a summation of blinking but a spatial and temporal extension of the orbicularis oculi muscle activity engaging in blinking, and the classification of the present study can support the investigation of the temporal characteristics of patients with this disease.

Severe but temporary injury to rabbit orbicularis oculi muscle using dihematoporphyrin ether and laser photochemomyectomy

The use of local dihematoporphyrin ether (DHE) injections, followed by laser light activation, was investigated as a potential permanent myectomy treatment for muscle spasms, in particular blepharospasm and hemifacial spasm. DHE was injected into the eyelids of rabbits, followed by laser activation, as used in photochemotherapy. Four days after treatment, histological examination indicated that doses of greater than or equal to 0.5 mg of DHE and laser treatment with an energy density of at least 100 J/cm2 resulted in an almost total destruction of the orbicularis oculi muscle in the treated eyelid. The amount of muscle injury was dependent on both dose of DHE and energy density levels. Histologically, the tarsal glands and conjunctiva were damaged. Glandular tissue was markedly reduced, and the conjunctival epithelium showed hyperplasia and a loss of mucous cells. Six months after DHE and laser treatment, the majority of the muscle tissue had regenerated, although there was evidence of previous injury. While DHE injections combined with laser light activation were lethal to muscle at the site of treatment, this treatment was not permanent. The orbicularis oculi muscle retained its ability to regenerate. However, photochemomyectomy may be studied further as an adjuvant treatment to temporarily injure and debulk large muscles when botulinum toxin is contraindicated due to the large doses involved or as a permanent treatment when used together with an antimitotic agent such as doxorubicin.