Profile of patients with essential blepharospasm and hemifacial spasm in the two largest ophthalmology reference centers in Brazil

PURPOSE

Information is scarce regarding the comprehensive profile of patients with essential blepharospasm and hemifacial spasm in Brazil. The present study aimed to assess the clinical features of patients with these conditions, followed up in two reference centers in Brazil.

METHODS

The study included patients with essential blepharospasm and hemifacial spasm, followed up at the Departments of Ophthalmology at Universidade Federal de São Paulo and Universidade de São Paulo. Apart from demographic and clinical features, past stressful events related to the first symptoms (triggering event), aggravating factors, sensory tricks, and other ameliorating factors for the eyelid spasms were assessed.

RESULTS

A total of 102 patients were included in this study. Most patients were female (67.7%). Essential blepharospasm was the most frequent movement disorder [51/102 patients (50%)], followed by hemifacial spasm (45%) and Meige's syndrome (5%). In 63.5% of the patients, the onset of the disorder was associated with a past stressful event. Ameliorating factors were reported by 76.5% of patients; 47% of patients reported sensory tricks. In addition, 87% of the patients reported the presence of an aggravating factor for the spasms; stress (51%) was the most frequent.

CONCLUSION

Our study provides information regarding the clinical features of patients treated in the two largest ophthalmology reference centers in Brazil.

Epidemiology of benign essential blepharospasm: A nationwide population-based retrospective study in Taiwan

IMPORTANCE

This study provides a nationwide, population-based data on the incidence of benign essential blepharospasm in Asian adults.

BACKGROUND

To describe the incidence, patient demographics, and risk factors associated with benign essential blepharospasm.

DESIGN

Population-based retrospective study.

PARTICIPANTS AND SAMPLES

A total of 1325 patients with benign essential blepharospasm were identified.

METHODS

Patients with diagnosis of blepharopsasm between January 2000 and December 2013 were sampled using the Longitudinal Health Insurance Database 2000. Secondary blepharospasm that may be related to neurological, trauma, and ocular surface disease were excluded.

MAIN OUTCOME MEASURED

Multivariate conditional logistic regression was used to estimate the odds ratios for potential risk factors of benign essential blepharospasm.

RESULTS

The mean annual incidence was 0.10‰ (0.07‰ for males, and 0.12‰ for females). The peak incidence was in the 50 to 59-year-old age group (0.19‰). People living in urban regions have more risk of developing blepharospasm comparing to people living in less urban regions (p <0.01). White-collar workers also have higher chance of having blepharospasm (p<0.001). Significant difference between control group and case group in hyperlipidemia (p <0.001), sleep disorders (p <0.001), mental disorders (depression, anxiety, obsessive compulsive disorder) (p <0.001), dry eye-related diseases (dry eye, Sjögren's syndrome) (p <0.001), Parkinson's disease (p <0.004), and rosacea (p <0.021) were also identified.

CONCLUSIONS AND RELEVANCE

Higher level of urbanization, white-collar work, sleep disorders, mental health diseases, dry eye-related diseases, Parkinsonism, and rosacea are possible risk factors for benign essential blepharospasm.

Hemifacial spasm

Hemifacial spasm (HFS) is a peripherally induced movement disorder causing clonic or tonic contractions of the facial muscles. HFS is usually unilateral and sporadic. It may be primary (mainly attributed to vascular compressions of the seventh cranial nerve in the posterior fossa) or secondary to facial nerve or brainstem damage. The two forms share a number of features but may differ in clinical presentation (simultaneous involvement of the upper and lower facial muscles in secondary forms). The spasm-related electromyogram activity is probably generated by ephaptic transmission, due to local demyelination at the entry zone of the facial nerve root (possibly owing to nerve damage caused by a compressing cerebral vessel). These findings suggest the "nerve origin hypothesis" as the main pathophysiological mechanism underlying HFS. Medical treatment (anticonvulsants or GABAergic drugs) is generally ineffective. Microvascular decompression of the facial nerve can achieve marked improvements in the majority of patients, although recurrences and complications are not uncommon. Local (orbicularis oculi or lower facial muscles) injection of Botulinum toxin (BoNT) is therefore considered the preferred symptomatic treatment for primary HFS. The long-term efficacy and safety of BoNT have been documented by clinical studies.

Young onset Hemifacial Spasm in patients with Chiari type I malformation

Hemifacial spasm (HFS) resulting from Chiari type I malformation (CIM) is rare. We retrospectively evaluated five patients with CIM and HFS among a series of 103 subjects. The frequency of HFS associated to CIM was of 4.85%. The clinical profile did not differ from the classical primary cases except for young-onset development of facial spasms in patients with CIM. Three patients were treated with BTX-A injections with favorable outcome. Although rare HFS may be associated with CIM especially in young subjects with peculiar phenotypic characteristics (short neck). Moreover, BTX may be an alternative to posterior fossa decompression in selected cases.

Young onset hemifacial spasm

INTRODUCTION

Hemifacial spasm (HFS) frequently affects middle aged individuals and the clinical features and etiology have been well reported. However, there is limited data on the exact pathogenesis in young-onset HFS. If age is a major determinant of the etiology or influences the presentation of HFS, there may be clinical differences between the young and elderly HFS patients.

OBJECTIVES

We determined the prevalence, clinical and imaging features of young-onset HFS (age of onset<or=30 years) in a tertiary referral center. These data were compared with old onset (age of onset>or=65 years) HFS patients.

METHODS

We examined consecutive patients clinically diagnosed with HFS in a tertiary referral center. The clinical (demographics, clinical presentation, severity of HFS, associated medical conditions and other variables) and imaging findings of young onset patients and old onset patients were tabulated and compared.

RESULTS

Amongst 230 consecutive HFS patients, 15 (6.5%) were young-onset HFS and 50 (21.7%) were old-onset HFS. In the young-onset HFS, the mean age of onset of symptoms was 26.5+/-6.5 (6-30) years, with 80% women and 75.0% of young onset HFS having neurovascular compression (NVC) of the root exit zone (REZ) of the facial nerve on the ipsilateral side; 86.7% had initial onset of twitching in the upper eyelids that later progressed to the lower facial muscles. While the prevalence of hypertension, diabetes mellitus and other associated vascular disorders in late onset HFS was higher than in young onset groups, the clinical features and frequency of NVC of the facial REZ between the two groups were similar.

CONCLUSIONS

We demonstrated a 6.5% frequency of young-onset HFS in our cohort of HFS and their clinical presentation was similar to the old onset patients. Genetic, anatomic or other unidentified factors may contribute to NVC in young-onset HFS.

Exploring the relationship between Parkinson's disease and hemifacial spasm

Case reports of co-existent Parkinson's disease (PD) and hemifacial spasm (HFS) suggest that there may be a relationship between these conditions. Three of 300 (1%) PD patients presented with HFS compared with 0/300 (0%) controls. The mean age of the three PD patients with HFS was 68.7 +/- 8.0 (60-76) years, with the majority having left-sided HFS. All three patients developed HFS symptoms at around the onset of PD and they were significantly older than the 100 patients with HFS alone (P < 0.05). Our study demonstrated no significant increased risk of HFS amongst the general PD population and hence HFS symptoms are unlikely to be of clinical importance for most PD patients.

A Comparative Study of Primary and Secondary Hemifacial Spasm

BACKGROUND

Hemifacial spasm (HFS) is a common movement disorder.

OBJECTIVE

To evaluate possible differences in the demographic and clinical features between primary and secondary HFS.

DESIGN

In-person interview using a standardized questionnaire to collect demographic and clinical data.

SETTING

A multicenter study that included patients with HFS attending 3 Italian academic centers. Patients Two hundred fourteen patients with HFS.

MAIN OUTCOME MEASURE

A complete neurological examination assessed the current muscle distribution of spasm and the presence of synkinetic movements between upper and lower facial muscles.

RESULTS

The study sample comprised 214 patients with HFS, 81 men and 133 women, having a mean +/- SD age of 65.9 +/- 12.3 years; 164 patients were classified as having primary HFS and 50 patients (48 postparalytic and 2 symptomatic cases) were classified as having secondary HFS. Patients with primary and those with secondary HFS had similar mean +/- SD ages at onset (54.9 +/- 13.5 vs 57.0 +/- 12.8 years), male-female ratios (63:101 vs 18:32), right-sided-left-sided HFS (77:86 [1 bilateral] vs 21:28 [1 bilateral]), and frequencies of familial cases (2.9% vs 2.0%), respectively. Most patients (65.0%) with primary HFS had initial symptoms of periocular muscle contractions alone and had subsequent involvement of the lower facial muscles. Most patients (72.0%) with secondary HFS reported initial involvement of the upper and lower facial muscles simultaneously. Signs of synkinesis were present in primary (43.3%) and secondary (58.0%) HFS.

CONCLUSIONS

Patients with primary and those with secondary HFS share common demographic and clinical features, including sex distribution, age at onset, affected side of HFS, synkinesis, and rarity of familial cases. Signs of synkinesis were present in significant proportions of patients with primary or secondary HFS. The 2 forms differed in clinical presentation.

Case–control study of anxiety symptoms in hemifacial spasm

In a case-control study, we evaluated symptoms in nine different psychological domains in hemifacial spasm (HFS; using the Symptom Checklist-90R [SCL-90R]) and found the anxiety score to be significantly greater in HFS compared to healthy controls in both the univariate (P = 0.004) and multivariate analysis (adjusted for sex, age, marital status, and educational level; P = 0.002). Similar findings were obtained when comparison was made with an independent group of outpatient controls. Compared to outpatient controls, the HFS patients had a higher mean Hamilton Anxiety Rating Score (HAM-A; 10.0 +/- 8.0 [range, 0 to 28] vs. 5.0 +/- 5.0 [range, 0 to 25]; P = 0.004), and 19.5% had HAM-A score of 18 or above compared to 3.8% in controls (P = 0.02). Among the HFS patients, the mean anxiety score in SCL-90R was significantly higher in those defined with mild to severe anxiety under HAM-A compared to those without anxiety (74.0 +/- 6.0 vs. 48.0 +/- 13.0) (P < 0.0005). There was good correlation of the anxiety score with the HAM-A in HFS patients (r = 0.915; P < 0.0001). HFS patients with anxiety reported significant improvement of their symptoms (mean HAM-A score 19.0 +/- 5.0 vs. 11.0 +/- 6.0; P = 0.001) following appropriate management. As stress and anxiety can aggravate HFS, diagnosis and early management of anxiety symptoms can improve quality of life in these patients.

Benign Essential Blepharospasm: Risk Factors with Reference to Hemifacial Spasm

BACKGROUND

To identify risk factors associated with benign essential blepharospasm (BEB) with reference to hemifacial spasm (HFS). Persons with BEB and HFS experience similar physical symptoms, yet the two disorders have different etiologies.

METHODS

Patients with BEB (n = 159) or HFS (n = 91) were identified from two large neuro-ophthalmology clinics. Demographic, medical, behavioral, and psychological characteristics were obtained from chart review and a telephonic survey questionnaire.

RESULTS

The average age of BEB and HFS was 66 years. Most patients in both groups were retired, white, and female. BEB patients were more than two times as likely to meet the diagnostic criteria for generalized anxiety disorder than HFS patients (odds ratio, 2.13; 95% confidence interval, 1.22-3.72). There was no difference between the two groups regarding demographics, smoking, a family history of dystonia, Parkinson disease, Bell palsy, Tourette disorder, obsessive compulsive symptoms, history of head trauma, alcohol use, or caffeine consumption.

CONCLUSIONS

As compared to HFS, BEB was significantly more often associated with generalized anxiety disorder. Given the similarity of other clinical features of these two disorders, it is reasonable to conclude that anxiety is a cause not a consequence of BEB. Contrary to previous studies, BEB was not associated with obsessive-compulsive symptoms, head trauma, Parkinson disease, Bell palsy, Tourette disorder, or lack of smoking.

Ventrolateral medullary compression in hypertensive patients with hemifacial spasm

In a patient-controlled study, the authors demonstrated a significantly higher prevalence of rostral ventrolateral medulla (VLM) compression in hypertensive patients with hemifacial spasm (HFS) compared with age-, sex-, race-, disease duration-, and disease severity-matched normotensive patients with HFS (p = 0.02). Hypertensive HFS patients were more likely to have a greater severity of neurovascular compression at the VLM compared with normotensive HFS patients (p = 0.008). VLM compression is associated with risk of hypertension in this study population.

Behind the facial twitch: depressive symptoms in hemifacial spasm

BACKGROUND

Depression impairs psychosocial and occupational functioning and contributes to significant morbidity and mortality. Hemifacial spasm (HFS) causes social embarrassment and visual and verbal disability.

OBJECTIVE

We examined; (1) the prevalence and predictive factors of depressive symptoms (Becks Depression Inventory (BDI) and clinical assessment) in HFS and (2) the sensitivity and specificity of BDI as a screening and diagnostic tool in HFS.

METHODS

A large cohort of HFS patients in a movement disorders clinic was clinically evaluated and the BDI self-administered by patients. Univariate analysis and multivariate logistic regression were undertaken to investigate the effect of age, gender, body-mass index, duration and severity of HFS on the outcome of BDI score. ROC (receiver operating characteristics) analysis was utilized to evaluate the sensitivity and specificity and discriminative property of the scale.

RESULTS

There were 90 HFS patients with a mean age of 54.4+11.1 (35-79) years, comprising of 58.9% women and with a mean severity HFS score of 2.9+0.8 (range 1-4). The mean BDI score was higher in depressed HFS than in non-depressed HFS (19.7+6.7 vs 4.2+4.9, p<0.0001). Female gender and a younger age were risk factors (p=0.07). In the multivariate analysis, the severity of HFS was an independent predictor of BDI scores (p<0.0001). The AUC was 97.1% suggesting excellent discriminative property of BDI. For cut-off score of 12/13, the sensitivity was 93.3%, specificity 94.7%, Positive Predictive Value 77.8% and Negative Predictive Value 98.6%.

CONCLUSIONS

The prevalence of depressive disorder in HFS was 16.7%, with younger women at greater risk. The severity of HFS was positively correlated with the severity of depressive symptoms. The BDI can be a complimentary screening and/or diagnostic instrument for depressive disorder in HFS. Early diagnosis of at-risk patients will prevent unnecessary morbidity and mortality.

Prevalence of hemifacial spasm in Oslo, Norway

All patients seeking medical or surgical treatment for hemifacial spasm (HFS) in Oslo, Norway were identified in a service-based prevalence study. Only four hospital departments offered services for Oslo citizens with HFS. Fifty patients with HFS were treated. The total prevalence was 9.8 per 100,000. The prevalence increased with age to 39.7 among those older than 70 years. The use of antihypertensive drugs was significantly more common in HFS patients (36%) than in Oslo's general population.

[Radiosurgery of vestibular schwannomas after microsurgery and combined radio-microsurgery]

Significant morbidity is expected after microsurgery for recurrent or growing residual vestibular schwannoma (VS). In order to avoid this procedure, radiosurgery appeared as an interesting alternative. The purpose of this study is to analyze the results of Gamma Knife radiosurgery in this indication. Between July 1992 and January 2002, 60 patients (including 12 NF2 patients) underwent radiosurgical treatment after one or more attempts of surgical resection (including 27 growing remnant VS and 19 recurrent VS) and could be followed with enough informations, out of 103 patients (10% of the VS population treated during the same period). Mean interval between surgical removal and radiosurgery was 71.5 Months (1.8-127.8 Months). Technical difficulties during the procedure were observed in the 12 cases, mainly due to problems in identifying the target. Median follow-up was 51.6 Months. Four out of 58 patients (7%, confidence interval: 1.9-16.7) were diagnosed as failure. Statistical study failed to find significant parameters influencing failure. Facial and trigeminal nerves were not impaired while one case of severe bulbopontine radio-induced injury leading to a lower cranial nerve deficit was observed. These results show that, in spite of additional difficulties to treat these patients with radiosurgery, this treatment is efficient with acceptable morbidity and can avoid another microsurgical procedure. The strategy of planned combined micro-and radiosurgical treatment of large VS deserves additional investigations to be validated.

[Surgical removal of unilateral vestibular schwannomas after failed Gamma Knife radiosurgery]

One of the primary criticismes of vestibular schwannoma (VS) radiosurgery is that the risk of surgical morbidity is increased for patients whose tumor progresses after the procedures. We reviewed the French experience of operated patients after failed Gamma Knife radiosurgery. From July 1992 to January 2002, 25 out of the 1000 treated patients underwent another treatment procedure for a gamma knife failure. Excluding the NF2 patients, 21 patients have been operated and the present study shows the data collected for 20 of them. In order to analyze the difficulties observed during the surgery, a questionnaire was filled by the surgeons. The mean interval between radiosurgery and removal was 36 Months, from 10 to 83 Months. The mean increase in Volume was 559% (37 to 3036%, median 160%). Evolution of the Koos grading was found from 8 grade II, 10 grade III et 2 grade IV to 10 grade III and 10 grade IV. Patients have been operated for radiological tumor growth in 7 cases and for clinico-radiological evolution in 13 cases. In 9 cases, the surgeon considered that he had to face unusual difficulties mainly because of adhesion of the tumor to neurovascular structures. Tumor removal was total in 14 cases, near total in 4 cases and subtotal in 2 cases. One case of venous infarction was noticed at the second day following surgery responsible of hemiparesis and aphasia that gradually recovered. At last follow-up examination, facial nerve was normal (House and Brackmann grade I and II) in 10 cases while it was a grade III in 7 cases and grade IV and V in 3 cases. We recommend that the decision for surgical removal of growing vestibular schwannoma after Gamma Knife treatment should be done after a sufficiently long follow-up period. Our results show that the quality of removal and of facial nerve preservation might be impaired by radiosurgery in half of cases. However these results do not support a change in our policy of radiosurgical treatment of small to medium size vestibular schwannoma.

Higher prevalence of obsessive-compulsive symptoms in patients with blepharospasm than in patients with hemifacial spasm

OBJECTIVE

The prevalences of obsessive-compulsive symptoms in patients suffering from blepharospasm and in those with hemifacial spasm were determined. The two conditions have similar symptoms, but only blepharospasm is etiologically linked to basal ganglia dysfunction.

METHOD

After being interviewed with the Structured Clinical Interview for DSM-III-R, 13 patients with blepharospasm and 13 with hemifacial spasm completed the SCL-90-R and the Hamburg Obsession/Compulsion Inventory-Short Form.

RESULTS

Patients in the blepharospasm group had significantly more obsessive-compulsive symptoms, as indicated by higher scores on the Hamburg Obsession/Compulsion Inventory-Short Form, than the patients with hemifacial spasm. SCL-90-R scores were in the normal range for nine and eight categories, respectively (out of nine).

CONCLUSIONS

The findings provide additional support for the hypothesis that obsessive-compulsive symptoms are related to basal ganglia dysfunction.