Primary Blepharospasm

How to face the hemifacial spasm: challenges and misconceptions

Hemifacial spasm (HFS) is characterised by intermittent, brief or sustained, repetitive contractions of the muscles innervated by one facial nerve. It is one of the most frequent movement disorders affecting the face. However common and allegedly straightforward to diagnose, it might reveal as a challenge for clinicians in various situations. Indeed, it often needs prior exclusion of many other movement disorders affecting the face, with frequent phenomenological overlaps with blepharospasm, post-facial palsy, facial motor tics, etc. The clinical diagnosis shall be supported by modern brain imaging techniques, and sometimes electromyography, as some particular aetiologies may require specific treatment. Primary forms are associated with vascular compression of the ipsilateral seventh cranial nerve, whereas secondary forms can be caused by any injury occurring on the facial nerve course. This article proposes a global and organised approach to the diagnosis, and the ensuing therapeutic options, as many practitioners still use some inefficient medications when they encounter a case of facial spasm.

Eye-Closure Rate Modulation in Blepharospasm

Background

Blepharospasm (BSP) is a type of focal dystonia and a number of patients with BSP have relatives also affected by BSP. The objective of this study was to quantify eye closure rates during activities of daily living in individuals with BSP and individuals without BSP with and without a first-degree relative with BSP.

Methods

37 patients with BSP (BSP group), 10 asymptomatic volunteers with a first-degree relative with BSP (RELATIVES group) and 25 asymptomatic volunteers without relatives with BSP (HV group) were recruited. The number of eye closures for each task were counted per 60 seconds, with a video recording. Within and between groups statistical comparisons of eye-closure rates were performed.

Results

The eye-closure rates of the RELATIVES group were not different from the BSP group for the majority of the tasks (except for watching television), and the HV group (for all tasks). The rate of eye closures in the BSP group compared to HV, was significantly increased in two tasks, resting and watching television.

Discussion

Eye closure rate varies considerably during activities of daily living in all groups. Individuals with first degree relative with BSP are more likely to have increased eye closure rate at rest.

Case report: Blepharospasm in peak-dose dyskinesia may benefit from amantadine in Parkinson's disease

Introduction

Blepharospasm is uncommon in Parkinson's disease, especially in the peak-dose dyskinesia period.

Case presentation

We herein present the case of a patient with PD who developed blepharospasm in the peak-dose dyskinesia period. The symptom was improved by taking amantadine.

Conclusion

The current report expands the phenomenology of peak-dose dykinesia in PD to include dystonic blepharospasm. This complication of levodopa therapy may respond to amantadine despite the dystonic appearance of movements.

Oxymetazoline hydrochloride ophthalmic solution, 0.1%, boosts the effects of botulinum toxin on blepharospasm: a case series

Background

Oxymetazoline hydrochloride ophthalmic solution (0.1%) is a medication used to treat blepharoptosis. Patients who suffer from blepharoptosis have low-lying eyelids that can hinder their vision. Oxymetazoline hydrochloride ophthalmic solution (0.1%) is prescribed to patients to improve their vision by lifting the upper eyelids. Blepharospasm consists of involuntary, bilateral orbicularis oculi muscle movements that result in twitching and eyelid closure. Botulinum toxin is a treatment used to treat blepharospasm by preventing muscle contraction; but it is not always effective.

Case presentation

The effects of treatment with both oxymetazoline hydrochloride ophthalmic solution (0.1%) and botulinum toxin are assessed in three patients: (1) Patient A, a 58-year-old Filipina woman; (2) patient B, a 62-year-old Korean woman; and (3) patient C, A 57-year-old Vietnamese woman. All patients had been diagnosed with blepharoptosis as well as blepharospasm. Each patient was given an opportunity to complete an optional survey to assess not only the efficacy of oxymetazoline hydrochloride ophthalmic solution (0.1%) together with botulinum toxin but also their perceived stress during the past month.

Conclusions

Administering botulinum toxin for the treatment of blepharospasm in patients A and B yielded the expected results; adding oxymetazoline hydrochloride ophthalmic solution (0.1%), a medical treatment for ptosis, to the treatment regimen yielded an unexpected reduction of blepharospasm. We propose that botulinum toxin and oxymetazoline hydrochloride ophthalmic solution (0.1%) can have a synergistic effect on reducing blepharospasm when used concomitantly. We present three cases in which combined use of botulinum toxin with oxymetazoline hydrochloride ophthalmic solution (0.1%) reduced blepharospasm, and propose possible reasons for such effects. We also discuss previous literature in agreement with the results of our cases.

Dystonia, chorea, hemiballismus and other dyskinesias

Hyperkinesias are heterogeneous involuntary movements that significantly differ in terms of clinical and semeiological manifestations, including rhythm, regularity, speed, duration, and other factors that determine their appearance or suppression. Hyperkinesias are due to complex, variable, and largely undefined pathophysiological mechanisms that may involve different brain areas. In this chapter, we specifically focus on dystonia, chorea and hemiballismus, and other dyskinesias, specifically, levodopa-induced, tardive, and cranial dyskinesia. We address the role of neurophysiological studies aimed at explaining the pathophysiology of these conditions. We mainly refer to human studies using surface and invasive in-depth recordings, as well as spinal, brainstem, and transcortical reflexology and non-invasive brain stimulation techniques. We discuss the extent to which the neurophysiological abnormalities observed in hyperkinesias may be explained by pathophysiological models. We highlight the most relevant issues that deserve future research efforts. The potential role of neurophysiological assessment in the clinical context of hyperkinesia is also discussed.

Smell and taste in idiopathic blepharospasm

The pathophysiology of blepharospasm is incompletely understood. Current concepts suggest that blepharospasm is a network disorder, involving basal ganglia, thalamus, cortex, and, possibly, the cerebellum. Tracing, imaging, and clinical studies revealed that these structures are also concerned with olfaction and taste. Because of this anatomical overlap, dysfunction of the chemical senses in blepharospasm is expected. Injections of botulinum toxin into the eyelid muscles are the first-line treatment of blepharospasm. Yet, the effects of botulinum toxin on the chemical senses have not been systematically assessed. To contribute to a better understanding of blepharospasm, olfactory and gustatory abilities were assessed in 17 subjects with blepharospasm and 17 age-/sex-matched healthy controls. Sniffin Sticks were used to assess odor threshold, odor discrimination, and odor identification. Results of these three Sniffin Sticks subtests were added to the composite olfactory score. The Taste Strips were applied to assess taste. In an adjacent study, we assessed the sense of smell and taste in eight subjects with blepharospasm before and 4 weeks after botulinum toxin treatment. Subjects with blepharospasm had significantly lower (= worse) scores for odor threshold and for the composite olfactory score than healthy controls, while odor discrimination, odor identification, and the composite taste score were not different between groups. The adjacent study revealed that botulinum toxin did not impact the chemical senses. In this study, subjects with blepharospasm had a lower (= worse) odor threshold than healthy controls. As olfaction is important in daily life, findings justify further research of olfaction in blepharospasm.

Characteristics of tear abnormalities associated with benign essential blepharospasm and amelioration by means of botulinum toxin type A treatment

PURPOSE

To investigate the characteristics of tear abnormalities with benign essential blepharospasm (BEB) and the effect of botulinum toxin type A (BTX-A) treatment.

STUDY DESIGN

Prospective and clinical study.

METHODS

Forty eyes of 40 patients (12 men and 28 women, ages 63.5 ±12.9) with BEB and tear abnormalities were enrolled.

RESULTS

The average scores for subjective symptoms as evaluated by the visual analog scale (VAS) were 46.3 and Dry Eye-Related Quality-of-Life Score (DEQS) were 63.7. The fluorescein breakup time (FBUT) was 2.7 ± 1.6 sec. Among fluorescein breakup patterns (FBUPs), dimple break, with the corresponding mechanism of decreased wettability was the most frequent, observed in 29 eyes (73%). The NEI score was 0.4 ± 0.7 and the van Bijesterveld score was 0.6 ± 0.8; the Schirmer 1 test value was 13.1 ± 9.4 mm. Eighteen patients received BTX-A treatment, and significant improvement was found in severity of subjective symptoms both on VAS and DEQS as well as for FBUT. The main FBUPs changed from dimple break to random break.

CONCLUSION

Tear abnormalities seen in BEB correspond to short BUT-type dry eye (DE), subclassified into decreased wettability DE in view of FBUPs.

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.

Botulinum toxin A (Dysport®): in dystonias and focal spasticity

Dysport®, a formulation of botulinum toxin A, blocks acetylcholine release at neuromuscular junctions causing denervation and temporary muscle paralysis. It is used to treat several medical conditions, including dystonias and focal spasticity. Subcutaneous Dysport® was effective in improving functional disability in adults with blepharospasm in a placebo-controlled trial with 16 weeks' follow-up, and in adults with hemifacial spasm in case series. Similarly, intramuscular Dysport® was effective in improving symptoms of cervical dystonia in adults, focal spasticity in adults with post-stroke upper limb spasticity and dynamic equinus spasticity in paediatric patients with cerebral palsy in placebo-controlled trials with up to 20 weeks' follow-up. However, in two 12-week, placebo-controlled trials in adults with focal lower limb spasticity (spastic equinovarus deformity after stroke and hip adductor spasticity associated with multiple sclerosis) intramuscular Dysport® had limited efficacy. Available longer-term data indicated that Dysport® treatment was effective over several treatment cycles in patients with cervical dystonia or upper limb spasticity. Dysport® was generally well tolerated in patients with dystonias or focal spasticity. Most adverse events were mild to moderate and transient.

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.

Exploding vs. imploding headache in migraine prophylaxis with Botulinum Toxin A

Migraine headache is routinely managed using medications that abort attacks as they occur. An alternative approach to migraine management is based on prophylactic medications that reduce attack frequency. One approach has been based on local intramuscular injections of Botulinum Toxin Type A (BTX-A). Here, we explored for neurological markers that might distinguish migraine patients who benefit from BTX-A treatment (100 units divided into 21 injections sites across pericranial and neck muscles). Responders and non-responders to BTX-A treatment were compared prospectively (n=27) and retrospectively (n=36) for a host of neurological symptoms associated with their migraine. Data pooled from all 63 patients are summarized below. The number of migraine days per month dropped from 16.0+/-1.7 before BTX-A to 0.8+/-0.3 after BTX-A (down 95.3+/-1.0%) in 39 responders, and remained unchanged (11.3+/-1.9 vs. 11.7+/-1.8) in 24 non-responders. The prevalence of aura, photophobia, phonophobia, osmophobia, nausea, and throbbing was similar between responders and non-responders. However, the two groups offered different accounts of their pain. Among non-responders, 92% described a buildup of pressure inside their head (exploding headache). Among responders, 74% perceived their head to be crushed, clamped or stubbed by external forces (imploding headache), and 13% attested to an eye-popping pain (ocular headache). The finding that exploding headache was impervious to extracranial BTX-A injections is consistent with the prevailing view that migraine pain is mediated by intracranial innervation. The amenability of imploding and ocular headaches to BTX-A treatment suggests that these types of migraine pain involve extracranial innervation as well.