Surgical Management of Essential Blepharospasm

Extended frontalis orbicularis oculi muscle flap shortening for treating refractory apraxia of eyelid opening associated with blepharospasm

BACKGROUND

Refractory apraxia of eyelid opening (AEO) is mostly unresponsive to botulinum toxin (BTx) and inevitably leads to functional blindness. To treat this challenging condition, an innovative surgical technique was proposed.

METHODS

The extended frontalis orbicularis oculi muscle (FOOM) flap shortening consisting of frontalis suspension, partial myectomy, and myotomy in situ of eyelid protractors was applied to treat refractory AEO associated with blepharospasm. The postoperative outcomes and patient satisfaction were evaluated.

RESULTS

Seven patients (mean ages 64.1 ± 3.9 years) of 14 eyelids in total had an average flap shortening distance of 24.4 ± 1.3 mm. During a mean follow-up of 31.6 ± 11.4 months, the average BTx dosage reduced from 58.6 ± 12. 1 units to 30.0 ± 8.2 units, with a mean injection interval decreasing from 2.3 ± 0.5 months to 4.1 ± 0.9 months (p < 0.05). Palpebral fissure height increased from 1.4 ± 0.5 mm to 7.9 ± 0.7 mm, and the disability scale decreased from 78.8% ± 7.2% to 12.6% ± 7.0% (p < 0.05). The postoperative BTx dosage and frequency were significantly reduced. All patients restored voluntary eyelid opening and reported high postoperative satisfaction (average Likert scale 4.6 ± 0.5).

CONCLUSION

Extended FOOM flap shortening is an effective treatment to solve refractory AEO associated with blepharospasm.

Evaluation of Blepharoptosis in Patients With Refractory Blepharospasm by VISA-Video Recordings, Idiosyncratic Expressions, Sensory Tricks, and Ancillary Procedures

BACKGROUND

How to evaluate blepharoptosis concomitantly presented with refractory and uncontrollable blepharospasm? To date, there is a paucity of publications on the ideal evaluation methods. An innovative method-video recordings, idiosyncratic facial expressions, sensory tricks, and ancillary procedures (VISA)-is developed for preoperative evaluation, and the surgical outcomes are demonstrated.

METHODS

A retrospective study using VISA for blepharoptosis evaluation was conducted on 51 patients with refractory blepharospasm. Based on the evaluation, patients underwent blepharoptosis correction simultaneously besides the selective myectomy and myotomy in situ of the eyelid protractors for blepharospasm. Preoperative and postoperative palpebral fissure height, margin reflex distance 1, ptosis severity, and levator function were assessed to identify the effectiveness of VISA. All the procedures were performed by the senior author C.-S.L.

RESULTS

There were 42 patients diagnosed with essential blepharospasm and 9 patients with Meige syndrome. Forty-one patients (82/102 eyelids [80.4%]) had concomitant blepharoptosis and blepharospasm. Ptosis severity was mild in 21 eyelids (25.6%), moderate in 12 eyelids (14.6%), and severe in 49 eyelids (59.8%). Preoperative/postoperative (6 months) values of palpebral fissure height, margin reflex distance 1, and levator function were 4.70 ± 2.45 mm/8.35 ± 1.33 mm (P < 0.05), -0.30 ± 3.19 mm/3.73 ± 1.05 mm (P < 0.05), and 13.07 ± 2.56 mm/13.68 ± 2.34 mm (P < 0.05), respectively. Undercorrection and revision rate reported 9.8% and 3.7%, individually.

CONCLUSIONS

VISA approach overcomes the difficulty of blepharoptosis assessment in patients with refractory blepharospasm. It provides useful preoperative information required for adequate blepharoptosis correction in blepharospasm surgery and yielded desirable outcomes.

Disabling muscle of Riolan: A novel concept of orbicularis oculi myectomy for refractory benign essential blepharospasm

PURPOSE

To examine the effectiveness of orbicularis oculi myectomy with disabling the muscle of Riolan in patients with benign essential blepharospasm refractory to botulinum toxin-A (BTX-A) injection.

METHODS

This retrospective, observational study included 25 patients. After removal of the redundant skin and underlying orbicularis oculi muscle (OOM) with or without extended OOM removal to the area of the superior orbital rim, the tarsal plate and the gray line were vertically severed at 2 points to disable the muscle of Riolan. The surgical effectiveness was evaluated using the visual analogue scale (VAS), functional disability score (FDS), and the presence or absence of necessity or enhanced effectiveness of BTX-A injection after surgery.

RESULTS

The symptoms improved in 23 patients (92.0%). The VAS and total FDS were significantly improved from 8.4 ± 1.7 to 4.0 ± 2.4 (reduction rate, 50.7 ± 35.6%) and from 74.6 ± 22.2 to 34.7 ± 25.3 (reduction rate, 53.4 ± 27.4%) after surgery, respectively (both, p < 0.001). Among the 23 patients whose symptoms improved after surgery, BTX-A injection was not required in 11 of them (47.8%). Among the remaining 12 patients (52.2%), the effectiveness of BTX-A was post-operatively enhanced in eight patients (34.8%). There were no serious complications, and none of the patients experienced madarosis.

CONCLUSION

Disabling the muscle of Riolan is a valuable option of OOM myectomy in patients with refractory benign essential blepharospasm, without the development of serious complications, including madarosis.

SURGICAL ASPECT OF BLEPHAROSPASM TREATMENT: A CASE REPORT

Blepharospasm is an idiopathic condition characterized by involuntary eyelid closure mainly caused by bilateral tonic-clonic contractions of the orbicularis oculi muscle. It results in patient inability to open their eyes, thus significantly impairing their ability to perform activities of daily living. First-line treatment for blepharospasm are primarily botulinum toxin type A injections. However, surgical procedure as a treatment option can also be taken in consideration. In this overview, we present a case of a 75-year-old female patient who received surgical treatment as per Anderson's method after being treated with botulinum toxin type A for 3 years. This form of therapy proved to be an extremely successful permanent solution in the treatment of severe cases of refractory blepharospasm, without any long-term complications, especially ectropion and lagophthalmos.

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.

Treatment of Blepharospasm/Hemifacial Spasm

OPINION STATEMENT

The treatment of both hemifacial spasm (HFS) and blepharospasm (BEB) requires making the appropriate clinical diagnosis. Advance imaging and electrophysiologic studies are useful; however, one's clinical suspicion is paramount. The purpose of this review is to summarize current and emerging therapies for both entities. Botulinum toxin (BTX) remains the first-line therapy to treat both conditions. If chemodenervation has failed, surgery may be considered. Due to the risks associated with surgery, the benefits of this option must be carefully weighed. Better surgical outcomes are possible when procedures are performed at tertiary centers with experienced surgeons and advanced imaging techniques. Microvascular decompression is an efficacious method to treat HFS, and myectomy is an option for medication-refractory BEB; the risks of the latter may outweigh any meaningful clinical benefits. Oral agents only provide short-term relief and can cause several unwanted effects; they are reserved for patients who cannot receive BTX and/or surgery. Transcranial magnetic stimulation has gained some traction in the treatment of BEB and may provide safer non-invasive options for refractory patients in the future.

Orbicularis oculi myo-osseous fixation: a new treatment for benign essential blepharospasm and blepharospasm associated with diffuse facial dystonia (meige syndrome)

BACKGROUND AND OBJECTIVE

This article describes a novel surgical procedure, myo-osseous fixation, as an adjunct therapy for patients with reduced or poor response to repeated botulinum toxin injections for essential blepharospasm and Meige syndrome.

PATIENTS AND METHODS

The small-incision, rapidly healing, rapidly performed technique uses self-drilling titanium screws tightly engaged with a compression wrench. The screws fixate the periorbital orbicularis oculi muscle to bone, creating mechanical resistance to outer portions of the orbicularis muscle involved in debilitating involuntary contractions.

RESULTS

Eleven of the treated 12 patients experienced immediate improvement in function. Each responding patient noted enhanced effect of subsequent botulinum toxin injections at previously ineffective doses. The benefit was substantial and sustained for 6 months in 9 of 12 patients. Decreased brow depression during forced closure, forced frown, and brow elevation at rest was apparent in all patients postoperatively. Although the brow elevation effect was reduced after 6 months, reduced brow depression during forced closure still was easily demonstrated in most patients. Complications included a nodular bump over the brow, more commonly found when large titanium screws were used, transient headache, and easily removed dislodged screw.

CONCLUSION

Initial data suggest that this procedure appears safe, well tolerated, and useful in the treatment of patients with essential blepharospasm and Meige syndrome responding poorly to botulinum toxin therapy.

What is new in the era of focal dystonia treatment? Botulinum injections and more

PURPOSE OF REVIEW

The treatment options for the management of dystonias continue to evolve and improve. Clinical outcomes, however, are not predictably consistent using a single treatment regimen in all patients.

RECENT FINDINGS

Botulinum toxin is still considered the best treatment option for the treatment of focal dystonias: blepharospasm, hemifacial spasm, and apraxia of eyelid opening. New findings indicate that physicians may be a little more aggressive with the dosage when the disease progresses. A new formulation of botulinum toxin has been produced that includes no proteins and may address the immunoresistance that can occur with prolonged use. Additional systemic medications may be helpful as adjuncts only in selected cases. Improved surgical techniques are now more successful and cause fewer complications. Therefore, many refractory cases are now offered a surgical approach alone or in combination with botulinum toxin.

SUMMARY

There have been recent therapeutic developments in the treatment of ocular dystonias.