Reflex blepharospasm

Increased pupillary constriction velocity in benign essential blepharospasm associated with photophobia

We evaluated whether the pupillary light reflex is altered in benign essential blepharospasm patients. Twenty-three patients with benign essential blepharospasm, 47 with reflex blepharospasm, and 29 dry eye disease controls were included. Pupillary light reflex-related parameters were measured under mesopic (10 lux) and photopic illuminance (200 lux) using an infrared pupillometer. Additionally, we assessed photophobia grade, eyelid function, and dry eye disease-related parameters. There were no differences in age, sex predominance, or dry eye disease-related parameters among the three groups, or in photophobia grade and eyelid function between benign essential blepharospasm and reflex groups. Constriction velocity and maximum constriction velocity in the mesopic condition were significantly greater in the benign essential blepharospasm group (3.26 ± 0.56 and 5.27 ± 0.90 mm/s) than in reflex (2.86 ± 0.62 and 4.59 ± 1.00 mm/s) or dry eye disease groups (2.96 ± 0.46 and 4.72 ± 0.67 mm/s). Constriction velocity and maximum constriction velocity in the mesopic condition positively correlated with photophobia grade (r = 0.525 and 0.617, P = 0.025 and 0.006) in the benign essential blepharospasm group. Pupillary light reflex may be related to the pathophysiology of benign essential blepharospasm with photophobia. Further studies are required to reveal connections among pupillary light reflex, photophobia, and focal dystonia in benign essential blepharospasm patients with photophobia.

Resistance to eye opening in patients with disorders of consciousness

INTRODUCTION

Resistance to eye opening (REO) is a commonly encountered phenomenon in clinical practice. We aim to investigate whether REO is a sign of consciousness or a reflex in severely brain-injured patients.

METHODS

We recorded REO in chronic patients with disorders of consciousness during a multimodal diagnostic assessment. REO evaluations were performed daily in each patient and clinical diagnosis of unresponsive wakefulness syndrome (UWS), minimally conscious state with (MCS+) or without (MCS-) preserved language processing was made using the Coma Recovery Scale-Revised (CRS-R).

RESULTS

Out of 150 consecutive patients, 79 patients fit inclusion criteria. REO was seen in 19 patients (24.1%). At the group level, there was a significant relationship between the presence of REO and the level of consciousness. We also observed a difference in the repeatability of REO between patients in UWS, MCS- and MCS+. Out of 23 patients in UWS, six showed REO, in whom five showed atypical brain patterns activation.

CONCLUSION

Our findings suggest a voluntary basis for REO and stress the need for multiple serial assessments of REO in these patients, especially since most patients show fluctuating levels of consciousness.

Animal models of focal dystonia

Animal models indicate that the abnormal movements of focal dystonia result from disordered sensorimotor integration. Sensorimotor integration involves a comparison of sensory information resulting from a movement with the sensory information expected from the movement. Unanticipated sensory signals identified by sensorimotor processing serve as signals to modify the ongoing movement or the planning for subsequent movements. Normally, this process is an effective mechanism to modify neural commands for ongoing movement or for movement planning. Animal models of the focal dystonias spasmodic torticollis, writer's cramp, and benign essential blepharospasm reveal different dysfunctions of sensorimotor integration through which dystonia can arise. Animal models of spasmodic torticollis demonstrate that modifications in a variety of regions are capable of creating abnormal head postures. These data indicate that disruption of neural signals in one structure may mutate the activity pattern of other elements of the neural circuits for movement. The animal model of writer's cramp demonstrates the importance of abnormal sensory processing in generating dystonic movements. Animal models of blepharospasm illustrate how disrupting motor adaptation can produce dystonia. Together, these models show mechanisms by which disruptions in sensorimotor integration can create dystonic movements.

The grasp and other primitive reflexes

Primitive reflexes are typically present in childhood, suppressed during normal development, and may reappear with diseases of the brain, particularly those affecting the frontal lobes. In this review we discuss some historical aspects surrounding these reflexes, how they might be elicited and interpreted, and their potential clinical utility in modern neurological practice.

Excessive blinking in childhood: a prospective evaluation of 99 children

OBJECTIVE

To determine the characteristics and causes of excess blinking in children and to determine outcomes after treatment.

DESIGN

Prospective, noncomparative, consecutive case series.

PARTICIPANTS

Ninety-nine consecutive children who presented for evaluation of excessive blinking over a 2 year period.

METHODS

Children less than 16 years of age who had excessive blinking as their sole or major chief complaint underwent detailed history and ophthalmologic examination. Treatment was recommended based on clinical examination findings. Follow-up evaluations were performed at least 2 months after initial examination.

MAIN OUTCOME MEASURES

Etiology of excess blinking and patient characteristics in each diagnostic group.

RESULTS

The majority (89%) of children presented with bilateral excessive blinking. Boys outnumbered girls at a ratio of almost 2:1. The most common etiologies were anterior segment and/or lid abnormalities (37%), habit tics (23%), uncorrected refractive errors (14%), intermittent exotropia (11%), and psycogenic blepharospasm (10%). A history of neurologic disease was present in 22% of the patients but was not causally related to the excessive blinking in most cases. Vision-threatening disease was noted in 6% and was easily detected on standard clinical examination. Life-threatening disease was the cause in 4% of the children, but the presence of life-threatening disease was already known in all such patients.

CONCLUSIONS

Excessive blinking in children can occur because of a large number of potential problems. Most cases are caused by benign and/or self-limiting conditions. The cause can usually be determined after careful history and clinical examination and routine neurologic evaluation and neuroimaging is unnecessary.

Excessive closure of the right eye: a new sign of infarction in the territory of the ipsilateral right middle cerebral artery

In right middle cerebral territory infarction a new sign, excessive closure of the right eye ipsilateral to the lesion and mild closure of the left eye on command, was noted. The excessive ipsilateral eye closure was not observed on spontaneous eye closure.

Reflex blepharospasm associated with bilateral basal ganglia lesion

A patient with a bilateral striatal lesion secondary to anoxia presented reflex blepharospasm associated with parkinsonism and dystonia in the limbs. The blink reflex excitability curve was enhanced and the R-2 response prolonged as in patients with essential blepharospasm. The findings in this patient support the notion that blepharospasm may be secondary to basal ganglia dysfunction through abnormal facilitation of reticular formation neurons controlling facial nucleus motoneuron excitability.

A case of bilateral ptosis associated with cerebral hemispheric lesions

Ptosis occurs in a variety of disorders including myasthenia gravis, oculomotor palsy, Horner's syndrome and brain stem disorders. There are also supranuclear lesions causing blepharoptosis. The latter disorders are reflex blepharospasm, apraxia of eyelid opening and Meige's syndrome. Since the total number of bilateral ptosis associated with cerebral hemispheric lesions is very few, whether the responsible lesions are located in the nondominant hemisphere or bilateral hemispheres are still controversial. We report here a case of bilateral cerebral ptosis that occurred in association with cerebral infarction of the nondominant hemisphere.

Facial dystonia: clinical features, prognosis and pharmacology in 31 patients

The natural history and response to different treatments were assessed in 31 consecutive patients with blepharospasm (BS) and/or oromandibular dystonia (OMD). The mean age at onset was 52.4 years and there was a female preponderance of 2.5 to 1. Ocular symptoms preceded the onset of blepharospasm in more than 50% of the affected patients, whereas psychiatric and dental problems prior to the onset of focal dystonia were found in 10% and 13% of the cases respectively. Dystonia elsewhere, mainly in the craniocervical area, was found in 23% of patients and appeared to follow a somatotopic progression. The first 2-3 years of history were crucial for the spread of dystonia to other face and body parts. When OMD was the first symptom, a lower tendency of dystonia to progress elsewhere was observed. A putative cause was found in 14% of patients who showed clinical and radiographic evidence of basal ganglia or rostral brainstem-diencephalon lesions. The response to different drugs was inconsistent although transient improvement was induced by haloperidol in 6 patients, by L-Dopa plus deprenyl in 3 patients, by trihexyphenidyl in 2 patients and by clonazepam in 2 patients. One, apparently spontaneous, remission was observed. Botulinum A toxin was injected in the orbicularis oculi of 8 patients affected by BS: moderate to marked improvement lasting 5 to 30 weeks (mean 14.5 weeks) was achieved in all cases; transient ptosis, lasting 1 to 3 weeks, occurred in 3 cases.

Hysterical symptoms in ophthalmology

Ophthalmologic symptoms are often not sufficiently accounted for by organic pathology. The complaints of these patients have been labeled hysterical, psychogenic, non-organic, or functional. The psychiatric nosology in this area may be the most confusing in the whole field of clinical medicine. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) offers a classification designed to reduce non-empirical concepts and ideology to a minimum. On this background, we discuss the hysterical symptoms encountered in clinical ophthalmology with special emphasis on psychogenic amblyopia and blepharospasm. Motor symptoms are commonly not of psychogenic origin. It is suggested that ophthalmologists are most likely to treat patients with psychogenic symptoms, using suggestion, patience, and reassurance. Few patients require psychiatric consultation and a specific psychiatric therapy. The association of hysteria with organic brain disease and the issue of symptom lateralization are briefly discussed. Eventually, we reject the psychoanalytic approach and suggest that the concept of abnormal illness behavior and the neurobiological models involving corticofugal inhibition, primitive reflex mechanisms, and an attention disturbance, serve best to understand the nature of the phenomenon hysteria.

Apraxia of eyelid opening secondary to right hemisphere infarction

A variety of eyelid movement abnormalities have been attributed to lesions of the central nervous system. Apraxia of lid movements, and especially of lid opening, has received the least attention. We present 2 cases of lid opening apraxia and propose that this abnormality may be due to right hemisphere dysfunction.

Blepharospasm accompanying hypoxic encephalopathy

Severe bilateral blepharospasm with left hemiplegia occurred in a 50-year-old woman, who developed cardiac arrest following ventricular aneurysmectomy. The blepharospasm was present constantly, even during sleep, and increased during attempts at voluntary eye opening. CT scan revealed multiple hypodense areas involving basal ganglia bilaterally and the right perisylvian area. The blepharospasm improved gradually over a 6-month period, although the left hemiplegia remained unchanged.

Abnormal facial movements. Guide to differential diagnosis

Spontaneous facial movements are disturbing to those who have them, yet some such movements are benign and cause no more than cosmetic embarrassment. Other abnormal facial movements, however, are more serious and can be associated with neurologic disorders such as multiple sclerosis, brainstem tumor, peripheral neuropathy, and Guillain-Barré syndrome. Occasionally, an abnormal movement of the face is the first sign of such an underlying disorder. Accurate differential diagnosis of these perplexing movement disorders is imperative in determining prognosis.

Glabellar reflex habituation in mentally retarded adults

The glabellar tap reflex has been studied in 88 adults with mental retardation and 20 normal controls. None of the 20 controls had abnormal response to glabellar tap. All the subjects with mental retardation had abnormal response to glabellar tap, 80 subjects had 'no habituation' and eight subjects had 'poor habituation' of response to glabellar tap. Thirty-nine subjects, with Down's syndrome, Prader-Willi syndrome and with gross cerebral pathological states with or without motor deficits had 'no habituation' of response to glabellar tap. Of the remaining 49 subjects with unidentified aetiological diagnosis of mental retardation, 41 subjects had 'no habituation' and eight subjects had 'poor habituation' of response to glabellar tap. Age and sex had no significant effect on the response to glabellar tap in the subjects studied. The possible physiological mechanisms responsible for the abnormal response to glabellar tap have been discussed.

Blink reflexes in severe traumatic coma

Blink reflexes were studied in 21 patients in coma after severe head injury. Our observations suggest that blink reflexes are a simple, objective, neurophysiological test to evaluate brainstem function. Correlations between these reflexes and the anatomoclinical stanges of coma and the Glasgow coma scale have been established. Presence of the early R1 component shows the integrity of at least a part of the pontine structures. The appearance of the late R2 component is correlated with a better chance of recovery from coma.

[Idiopathic blepharospasm. Clinical and electrophysiological investigations in 27 patients (author's transl)]

Idiopathic blepharospasm is reexamined and the differential diagnosis discussed on the basis of the signs and symptoms of 27 unpublished cases. As in tardive dyskinesia, middle-aged and elderly women are mostly affected. Contrary to general opinion, spontaneous improvement occurred in about one-fifth of the patients. The habituation of the orbicularis oculi reflexes (investigated electromyographically) was diminished in 52% of the patients. These and other symptoms indicate an organic cerebral lesion as the main cause of the disease. Similarities existing between blepharospasm and torticollis spasticus are discussed.

Gaze-evoked blepharoclonus

Painful bilateral orbicularis clonus on eccentric gaze developed in 2 patients with demyelinating disease. This unusual phenomenon was of variable intensity but persisted for years and did not respond to phenytoin or carbamazepine therapy.

The blink reflex in coma and after recovery from coma

Comparative studies of the blink reflex in a series of head injuries through the stages of coma and recovery from coma in a series of miscellaneous hemispheral lesions, and in a normal series, reveals that, although the principal centre for the R1 component of the blink reflex seems to be localised in the upper pons, the seat of the R2 late component is in the reticular system. The reappearance of this late component of the blink reflex in our cases of coma although seeming to depend on the integrity of the mesencephalic formation, correlates with the recovery of the patient's alertness. On the other hand, habituation of this reflex depends on the integrity of global cognitive function, rather than on any localised centre. The roles of the cortex, selective attention, and emotional factors, are discussed. The recovery of the normal habituation of the blink reflex obtained by glabellar tapping was found to be a useful sign in the follow up of patients recovering from concussion and other lesions, such as subdural haematomas and brain tumours, with global mental impairment.

Ptosis

Twenty-five examples of ptosis occuring with an acute stroke are analysed. Thirteen of these patients had hemispheral infarctions in which ptosis could not be explained by third nerve or sympathetic dysfunction. The ptosis in these `cerebral' cases was bilateral, with other factors such as pyramidal tract damage determining the asymmetry of the ptosis. In some patients, the eyelid was ptosed on the side of a hemiparesis, narrowing the palpebral fissure. The anatomical basis for this is probably damage to pyramidal neurones or their fibres. The 10 cases of ptosis in relationship to brain-stem infarction included two patients with isolated complete ptosis in one eye in association with a contralateral third nerve palsy.