Eyelid motor abnormalities in progressive supranuclear palsy

Eyelid motor abnormalities found in progressive supranuclear palsy are reviewed. Electrophysiological correlates of blepharospasm, levator inhibition (blepharokolysis) and supranuclear paralysis of lid closure are presented. Disorders of eyelid motility are not uncommon in progressive supranuclear palsy (PSP). They may be found in about one third of patients with this syndrome (Jackson et al., 1983; Golbe et al., 1989). This is not surprising since ocular and eyelid movements are highly coordinated, mainly in the vertical plane (Gordon, 1951; Kennard and Smith, 1963; Kennard and Glaser, 1964), and a supranuclear ophthalmoplegia with down gaze impairment is a cardinal feature of PSP (Steele et al., 1964). The spectrum of eyelid motor disorders described in PSP includes blinking abnormalities, lid retraction, blepharospasm, levator inhibition and supranuclear palsy of eye closure.

[Blepharospasm; results of treatment with botulin]

OBJECTIVE

Discussion of clinical symptoms and differential diagnosis of blepharospasm and treatment with botulinum A toxin. Blepharospasm is an involuntary spasmodic contraction of the eyelids. Within a few years 35%-70% of the patients becomes severely disabled.

DESIGN

Prospective, open study.

SETTING

Academical Medical Centre, Amsterdam.

METHOD

In the period 1985-1992 we have seen 85 patients with blepharospasm. Of these 69 were treated with botulinum toxin, a total of 436 treatments, with a mean dose of 25 IU for each eye.

RESULTS

The cause of blepharospasm was unknown in 71 patients. Secondary blepharospasm occurred in: peripheral facial palsy (one patient), herpes zoster infection of the trigeminal nerve (2), brain infarct (1), use of neuroleptics (2), progressive supranuclear palsy (2), Shy-Drager syndrome (1), kernicterus (1), and morbus Sjögren (4). There were 18 patients with autoimmune diseases. 77 (91%) patients had a (very) severe form of blepharospasm. Electromyographic registration revealed a dysfunction of M. levator palpebrae in 7 patients. More than 70% of the patients were free of symptoms for a mean period of two months after each treatment. Local side effects were seen in 61 (14%) of the 436 treatments: ptosis, haematoma, dry eyes, and diplopia.

CONCLUSION

Blepharospasm is a disabling disease and occurs sometimes in association with other neurological and ophthalmological diseases. Botulinum A toxin is a safe and effective therapy. Electrophysiological investigation is important in the differential diagnosis; it is unnecessary to do CT or MRI routinely.

[The use of therapeutic soft contact lenses for eliminating blepharospastic blindness in eye burns of mild to moderate degrees of severity]

Application of soft contact lens made of hi-hydrofiled polymeric material for patients with blepharospastic blindness makes it possible to remove or considerably diminish the corneal syndrome in slight and middle gravity burns. Most patients could be returned to their ranks and occupations.

Botulinum A toxin for treatment of aberrant facial nerve regeneration

Twelve patients with involuntary synkinetic eyelid closure were given 40 injections of botulinum A toxin. Temporary improvement in involuntary eyelid closure was observed in all 12 patients. Eleven of the 12 patients desired repeated injections. Dose requirements for this indication were compared with doses used in 697 injections in 112 patients with essential blepharospasm and Meige syndrome. Additionally, dose comparisons were made with 269 injections in 71 patients with hemifacial spasm. Dose requirements needed to treat aberrant regeneration of the facial nerve were substantially less than needed to treat blepharospasm and Meige syndrome. The dose requirement was similar to that in hemifacial spasm treatment. The reason for the differences probably relates to existing muscular denervation associated with hemifacial spasm and aberrant facial nerve regeneration.

A possible feline model for human blepharospasm

'Benign essential blepharospasm' is a human eyelid disorder of unknown aetiology characterized by involuntary, bilateral, and disabling spasmodic contracture of the orbicularis oculi muscle. Treatments are frequently disappointing. Here we report what might be a first step toward developing an animal model for exploring mechanisms of the disorder and potential treatments. We surgically implanted stimulating electrodes into brain areas known to supply input to the lateral division of the facial nerve nucleus to induce blinking by electrical stimulation. Single-pulse stimuli at or near the facial, parabrachial, red, and interstitial nuclei produced consistent stimulus-induced eyelid contractions. Responses were ipsilateral to stimulation, except for the interstitial nucleus where contralateral responses occurred. Little or no other movements of the face, head, or body occurred at eye-blink threshold voltages. When these sites were stimulated with pulse trains, eyelid closures followed stimulus frequency and tended to fuse into constant closure. Thresholds at each stimulus site remained constant during three days of testing. Drug treatments produced no consistent effect on eye-blink threshold from any stimulation site, even when general behaviour was affected. We conclude that these input pathways to the facial nucleus may contribute to blepharospasm and that future neurochemical and electrophysiological study of these pathways may produce a suitable animal model for understanding this disorder.

Blepharospasm hemifacial spasm and tremors possibly due to isolated caudate nucleus lesions

Isolated caudate nucleus lesions have only rarely been documented to cause focal extrapyramidal dysfunction. Two cases with possible infarcts in the head of left caudate nucleus presenting with contralateral tremors and blepharospasm with hemifacial spasm are reported. The possible mechanisms for such a presentation are discussed.

Effects of eyelid protractor excision for the treatment of benign essential blepharospasm

Data were analyzed from 37 patients with essential blepharospasm who had undergone upper eyelid protractor excision with brow suspension, and who had a median follow-up of 40 months (range, 12 to 83.5 months) after surgery. Of the 37 patients, 15 (40.5%) had sufficient relief of their spasms at their last follow-up; 22 patients (59.5%) had functionally significant recurrent or residual spasms after upper eyelid surgery. Of these 22 patients, 12 (55%) had recurrences more than six months after surgery, and four patients (18%) had recurrences more than one year after surgery. Patients with Meige syndrome were no more likely to experience recurrent spasms after upper eyelid surgery than patients who lacked a lower facial spasm component. Recurrence of symptoms was primarily the result of lower eyelid spasms in 11 patients (50%), upper eyelid spasms in one patient (5%), and all eyelids in six patients (27%). The location of recurrent spasms could not be ascertained in four patients (18%), with whom we had only telephone contact. Seven of 12 patients (58%) undergoing secondary procedures had relief from their spasms at the end of this study. Excluding those patients who chose to decline further surgery, 22 of 27 patients (81.5%) received satisfactory relief of symptoms after upper eyelid and, if needed, lower eyelid and repeat upper eyelid protractor excision. These long-term results are comparable to those reported previously for differential section of the facial nerve. Because the side effects of eyelid protractor excision are generally more acceptable, we recommend that when surgery is determined to be necessary for essential blepharospasm, upper eyelid protractor excision is the preferred surgical approach.

Blepharospasm associated with neurocysticercosis

We report a case of a 48-year-old woman who had a 4 years history of bilateral blepharospasm. CT-scan showed multiple intracranial calcifications (two of them in the left thalamus) corresponding to neurocysticerosis, and a lacunar infarction in right internal capsule area. To our knowledge this case is the first one reported in the literature of blepharospasm associated with (and perhaps symptomatic of?) neurocysticercosis.

Botulinum toxin as a treatment for blepharospasm, spasmodic torticollis and hemifacial spasm

Fifty-two patients affected by focal dystonia or hemifacial spasm were treated with repeated injections of botulinum toxin. A clinical improvement was observed in all patients with blepharospasm; clinical benefit had a mean duration of 10 weeks. Clinical results were less impressive, but also favorable in patients affected by spasmodic torticollis and by hemifacial spasm. In the latter, the incidence of drug-induced paresis was much higher than that observed in patients with blepharospasm, even though the doses of toxin injected were significantly lower.

Facial dystonia, essential blepharospasm and hemifacial spasm

Movement disorders, or dyskinesias, in the facial region may be categorized in several ways. Dystonic movement disorders in the cranial-cervical region, including essential blepharospasm, Meige syndrome and spasmodic torticollis, are characterized by uncontrollable squeezing movements in the face and neck. These disorders typically present in the fifth and sixth decades of life. Essential blepharospasm is particularly debilitating, as the involuntary eyelid closure that accompanies this condition may result in functional blindness with an otherwise normal visual pathway. Hemifacial spasm is an intermittent, unilateral, spasmodic contraction of the muscles innervated by the facial nerve. This disorder usually presents in the third or fourth decade and has a different underlying pathophysiology than the dystonias. Botulinum A toxin therapy has largely supplanted surgical intervention in the treatment of essential blepharospasm and hemifacial spasm.

Eyelid complications in trachoma: diagnosis and management

We present our experience (at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia) with the management of the trachomatous eyelid disease. Four major eyelid complications: cicatricial entropion, eyelid retraction, secondary blepharospasm and brow ptosis, are described and their management outlined. Nine hundred sixty patients with cicatricial entropion are presented with thorough discussion of the surgical procedures and results. The surgical management of eyelid retraction, blepharospasm and brow ptosis is geared to provide the ophthalmologist with a complete overview of the disease pattern.

[Involuntary lid closure caused by defective healing of facial paralysis and its treatment with botulinum toxin]

Unvoluntary lidclosure with movement of the mouth is not so rare in aberrant regeneration of nerve fibers after Bell's palsy. There was no therapy until now. 10 patients with this disease were treated with botulinum-toxin injections into the orbicularis muscle. For an average time of 11 weeks after injection there was a complete absence of synkinesis, followed by a time of 9 weeks of less complaints. Thus 2-3 injections might be sufficient treatment within a year. Complications worth mentioning, especially due to the reduced force of lidclosure, were not observed.

[Magnetic stimulation in patients with essential blepharospasm]

In 31 patients with an essential blepharospasm investigations were undertaken with transcranial cortical and cisternal magnetic stimulation of the facial nerve. Cortical stimulation was performed contralaterally, whereas cisternal stimulation was ipsilateral; the latencies and amplitudes of the potentials were determined. However, the extracranial part of the facial nerve was stimulated in the region of the stylomastoid foramen for neuromyography electrically. In most measurements the response potentials in the orbicularis oculi muscle and the levator labii muscle were determined. Cisternal stimulation yielded normal latencies, whereas cortical stimulation showed an increase of latency in some blepharospasm patients. A difference between the orbicularis oculi muscle and the levator labii muscle as known in patients with hemifacial spasm (20) could not be observed. The mean values of all latencies after cortical stimulation were normal. The method of transcranial magnetic stimulation is an important part of the complete investigation of patients with facial hyperkinesias as shown here in blepharospasm patients.

An epidemiological study of tics

We devised a questionnaire for estimation of each tic, and used a two-step investigation procedure, first by a parent questionnaire with 1,218 responses and second by a confirmatory telephone interview for 197 positive responses. The average estimated values were 11.3% for boys and 5.2% for girls. The prevalences were--blinking: 4.2%, head-jerking: 1.6%, shrugging: 1.2%, mouth-twitching: 0.6%, face-distortion: 0.5%, mouth-opening: 0%, throat-clearing: 2.7%, sniffing: 0.6%, and vocalization: 0.2%. According to the criteria in DSM-III-R, 5.1% of 1,218 had TTD, 2.2% had CMVTD, and 0.5% had Tourette disorder.

Blepharospasm associated with olivopontocerebellar atrophy

We report two cases of cranial dystonia (blepharospasm) associated with olivopontocerebellar atrophy (OPCA). The pathophysiology of blepharospasm appears to involve an increased excitability of the interneurons of the blink and corneal reflexes. It is hypothesized that blepharospasm associated with OPCA might be due to rostral brainstem lesions disrupting central dopaminergic and cholinergic pathways, resulting in disinhibition of brainstem reflexes or denervation supersensitivity of the facial nuclear complex.

Essential blepharospasm and related dystonias

Essential blepharospasm is an idiopathic disorder of progressive involuntary spasms of the orbicularis oculi and upper facial (corrugator, procerus) muscles. Blepharospasm literally means spasm of the eyelids; however, most patients with blepharospasm also have or will develop squeezing in the lower face and neck muscles (Meige's syndrome, orofacial dystonia, or oromandibular dystonia). Some patients develop dystonic, uncontrolled movements in areas outside the facial nerve distribution (segmental cranial dystonia or craniocervical dystonia). Chronic, forceful squeezing by the periocular muscles becomes debilitating for the patient and leads to functional and cosmetic eyelid deformities. Treatment has included a variety of modalities and oral medications that are of limited efficacy. Botulinum-A toxin injections have delivered the best temporary relief from this disorder, while the periorbital myectomy operation has been shown to give the best long-term results.

[Clinical and therapeutic aspects of essential blepharospasm]

The rare disease of blepharospasm which is nowadays believed to be an extrapyramidal dystonic movement disorder is discussed in clinical, differential diagnostic and therapeutic viewpoints. The abundant number of treatment methods proposed in the literature are critically reviewed. 13 cases are described, which were treated by our own surgical procedure - a modified neurotomy of branches of the parotid plexus. The importance of botulinum-toxin treatment in mild and moderate cases of blepharospasm, as well as the success and low rate of complications in neurotomy-treated patients with severe eyelid spasms, is stressed.

Use of botulinum toxin to treat blepharospasm in a 16-year-old with a dystonic syndrome

A 16-year-old boy with generalized dystonia had continuous, severe blepharospasm and facial grimacing. Local intradermal injections of botulinum A toxin greatly reduced the spasms and improved function. No side effects were observed. Local botulinum A toxin injections may be useful in the treatment of eyelid and facial spasms in patients with generalized dystonias.

Torticollis and blepharospasm in systemic lupus erythematosus

A case of torticollis and blepharospasm as the major manifestation of neurological involvement in systemic lupus erythematosis (SLE) is presented. A 56-year-old woman presented with blepharospasm in February 1985 and with torticollis in April 1985. She was diagnosed as having SLE in 1966, on the basis of positive LE cells, when she presented with fever and joint pains. There was no evidence that she had ever been on major tranquilizers. An attempt has been made to correlate the level of antibody titres and exacerbation of these movements with response to steroids. The possibility of an association between blepharospasm, torticollis, and autoimmune disorders has recently been considered.

Cranial dystonia, blepharospasm and hemifacial spasm: clinical features and treatment, including the use of botulinum toxin

Blepharospasm, the most frequent feature of cranial dystonia, and hemifacial spasm are two involuntary movement disorders that affect facial muscles. The cause of blepharospasm and other forms of cranial dystonia is not known. Hemifacial spasm is usually due to compression of the seventh cranial nerve at its exit from the brain stem. Cranial dystonia may result in severe disability. Hemifacial spasm tends to be much less disabling but may cause considerable distress and embarrassment. Patients affected with these disorders are often mistakenly considered to have psychiatric problems. Although the two disorders are quite distinct pathophysiologically, therapy with botulinum toxin has proven very effective in both. We review the clinical features, proposed pathophysiologic features, differential diagnosis and treatment, including the use of botulinum toxin, of cranial dystonia and hemifacial spasm.

The significance of ophthalmological symptoms in idiopathic blepharospasm

Two hundred and seventy-two patients with idiopathic blepharospasm were reviewed to establish the role of local eye disease in their illness. The majority of patients (57%) had symptoms at the onset of their illness such as dryness of the eyes, grittiness, irritation or photophobia suggesting eye lid or ocular surface disease. Detailed ophthalmological examination at the time of presentation had been carried out in 170 of the 272 cases; 64% of these patients had ocular symptoms, and 40% had demonstrable ocular surface or eye lid pathology. Such pathology was usually bilateral, chronic and resistant to local treatment. Blepharospasm developed in these patients after a long latent period, often of many years. Unilateral pathology was acute, normally responded well to local treatment, but was followed by the development of bilateral blepharospasm usually within six months. Amongst all 272 patients, those without ocular symptoms at presentation rarely developed them subsequently; if they did, there were no abnormal signs. The data suggest that ophthalmological disorders may trigger idiopathic blepharospasm in a substantial proportion of cases predisposed to develop this condition.

Involuntary closure of eyelids in parkinsonism. Electrophysiological evidence for prolonged inhibition of the levator palpebrae muscles

Involuntary closure of eyelids (ICE), a phenomenon variously interpreted as blepharospasm and apraxia of lid opening, is occasionally observed in parkinsonism. Nine patients (4 with Parkinson's disease, 2 with post-encephalitic parkinsonism, and 3 with supranuclear palsy) with prominent ICE, were studied by electromyographic recording of the eye muscles. ICE episodes were shown to be dependent upon prolonged, irregular inhibition of the normal tonic activity of the levator palpebrae superioris (LPS) muscle causing drooping of the upper eyelid without any corresponding activation of the orbicularis oculi (OO) muscle. Nevertheless, some degree of excessive, widely fluctuating OO activity was present in seven of the patients. Blepharocolysis (from Gr. blepharon, eyelid, and kolysis inhibition) is put forward as the term to designate ICE episodes resulting from abnormally long inhibition of the LPS muscles and should be differentiated electrophysiologically from blepharospasm, excessive OO muscles activity. Abnormal influences from basal ganglia acting on brainstem structures that regulate blinking may falicitate either of the two components of normal blinking resulting in ICE due to the predominance of LPS inhibition (blepharocolysis), the predominance of OO activation (blepharospasm) or a combination of the two.

Blepharospasm: a review of 264 patients

The natural history and response to different treatments have been evaluated in 264 patients with blepharospasm. The mean age of onset was 55.8 years and there was a female preponderance of 1.8 to 1. Dystonia elsewhere was found in 78% of patients, usually in the cranial-cervical region, and appeared to follow a somatotopic progression. A family history of blepharospasm or dystonia elsewhere was found in 9.5% of cases, which suggests a genetic predisposition. Ocular lesions preceded the onset of blepharospasm in 12.1% of cases. The response to drugs was inconsistent, although initial improvement was experienced by one fifth of patients treated with anticholinergics. Twenty-nine bilateral facial nerve avulsion operations were performed with benefit in 27 cases; but recurrences appeared in 22, on average one year after surgery. Botulinum toxin injections were performed in 151 patients. Significant improvement was achieved in 118 cases. Mean duration of benefit was 9.2 weeks. Transient ptosis and diplopia were the commonest side effects.

Pharmacological study in Meige's syndrome with predominant blepharospasm

Objective quantification of the symptoms of Meige's syndrome is difficult and has not been performed in the majority of pharmacological studies of Meige's syndrome published so far. The aim of the present study was to reexamine the therapeutic potential of biperiden, clonazepam, haloperidol, and lisuride using an objective method of quantification of the symptoms. Eleven patients received daily i.v. injections of biperiden, 5.0 mg; clonazepam, 1.0 mg; haloperidol, 2.5 mg; lisuride, 0.05 mg; and placebo in randomized order. The symptoms of the patients [idiopathic blepharospasm (IB), in 11 patients, oromandibular dystonia (OMD) in four patients] were quantified by a blind observer counting the frequencies and recording the cumulative duration of sustained spasms of IB and OMD over periods of 4 min before, and 15, 30, 60, 90, and 120 min after the i.v. challenges. Baseline quantification of IB and OMD was performed at identical intervals on randomized days of the trial. Significant improvement of the IB scores was found in response to biperiden and clonazepam and a trend toward improvement in response to lisuride (Wilcoxon test). Evaluation of the individual IB scores of each patient following the various drug challenges failed to predict the therapeutic potential of these drugs for subsequent oral treatment.

Correction of severe upper eyelid entropion

Lid splitting procedures have been described a long time ago. Despite repeated descriptions by various authors, the method is not widely known. We use a bare-tarsus technique, omitting any grafting. In addition, we found radial incisions at the nasal and temporal edges of the anterior lamella advantageous, as the often superimposed blepharospasm is abolished by the weakening of the tarsal part of the orbicularis muscle. Also, there is then less tendency for the recessed anterior lamella to creep back down to the lid margin.

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.

Blepharospasm and autoimmune diseases

We studied two patients, one with systemic lupus erythematosus and the other with myasthenia gravis, both of whom had coexistent blepharospasm. The blepharospasm occurred during exacerbations of the autoimmune diseases and improved with immunosuppressive therapy. These cases illustrate the possible association of blepharospasm and autoimmune disorders.

Progressive supranuclear palsy: report of a case with torticollis, blepharospasm, and dysfluency

A 76-year-old man is reported with advanced progressive supranuclear palsy (PSP) who developed a persistent, gradually progressive torticollis over a period of several months. Blepharospasm and dysfluency of the extrapyramidal type antedated the torticollis. This first report of torticollis in PSP reinforces previous notions that torticollis is related to pathologic changes in the striatum and brainstem. In addition, the combination of torticollis and blepharospasm in our patient supports the previous concept that these two "focal dystonias" have a common pathophysiologic mechanism. This also suggests that dysfluency in PSP may be an expression of a focal dystonia involving the muscles of articulation.

[3 cases of essential blepharospasm: pathogenetic problems correlated]

Three clinical cases of essential blepharospasm are discussed. On the basis of both therapeutical results and a review of the literature, pathogenetic hypothesis concerning such pathology are reexamined.

Involuntary movements in the elderly. Parkinson's disease and other causes

Dyskinesia is usually lifelong and progressive; therefore, physicians generally see the disorder in elderly patients. Medical treatment must be carefully selected on the basis of the cause of the dyskinesia. Parkinsonian dyskinesia is well controlled by drug therapy. However, patients can become less responsive to a drug after years of use and may experience unwelcome side effects. Cerebellar tremor is extremely disabling because it worsens with activity, but no satisfactory therapy is available. Senile, essential, and familial tremors are also intensified by action, but they can often be suppressed with a mild tranquilizer or a beta blocker. Drug treatment of blepharospasm and spastic dysphonia has been disappointing: Facial or laryngeal surgery is sometimes required. Tardive dyskinesia is caused by neuroleptic drugs, so the only therapy for the disorder is withdrawal of the offending drug.

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.

Blepharospasm with bilateral basal ganglia infarction

Severe, involuntary, forceful closure of both eyelids, along with dystonia and rigidity, followed hypoxic encephalopathy in a young man whose computed tomographic scan showed symmetric infarcts of the corpus striatum. Symptomatic blepharospasm can result from bilateral damage to the basal ganglia.

Sequelae of botulinum toxin injection

A total of 136 injections was given to 83 patients for strabismus (99 injections), blepharospasm (29 injections), and spastic entropion (eight injections). All four patients with entropion experienced temporary benefits and early recurrence; one injection resulted in temporary paralytic ectropion. Two of 13 patients treated for blepharospasm developed transient bilateral blepharoptosis. Temporary and related sequelae of extraocular muscle injection included one periocular hemorrhage, one total ophthalmoplegia, and a 44% incidence (29 of 66 patients) of blepharoptosis, which in two patients lasted more than six months. Within three days of injection one patient developed homolateral acute herpes simplex keratitis and a second died of an acute myocardial infarction. No causal relationship for these events has been established.

Psychological aspects of essential blepharospasm

Evaluation of 20 essential blepharospasm patients by using structured interview and psychological testing (MMPI, Rorschach) revealed characteristic pathological personality patterns in all cases. Recent losses or life change, marital conflict, and specific precipitating events were common. Test findings indicated unexpressed hostility, denial, and repression in a majority of women. Three of five men showed evidence of depression. This initial systematic investigation of psychological factors in blepharospasm supports the hypothesis that neurological and psychogenic factors may interact etiologically. The data suggest that personality, recent stress, and precipitating events warrant both clinical assessment and controlled research to determine the specificity and prevalence of these findings.

Blepharospasm: demographic and clinical survey of 250 patients

The pathophysiologic mechanisms of blepharospasm are poorly understood and the condition is often misdiagnosed. In an attempt to improve our understanding of blepharospasm, 250 patients with blepharospasm were surveyed. This heretofore largest reported series of blepharospasm patients reveals findings of clinical and demographic interest. For example, there is a 3 to 1 female preponderance, the age of onset is in the fifth or sixth decade of life in two-thirds of patients, the onset is usually gradual with progressive deterioration and involuntary spasms of other portions of face and body. Although specific ocular abnormalities may predispose a patient to blepharospasm, in most cases the blepharospasm is a form of focal dystonia often associated with other involuntary movements and neurologic abnormalities. Increased awareness of blepharospasm among primary care physicians as well as ophthalmologists, neurologists, psychiatrists, and other specialists should lead to early recognition and management of this disabling condition.

Blepharospasm--oromandibular dystonia (Meige's syndrome) misdiagnosed as secondary hemifacial spasm

Orofacial dyskinesia (Meige's syndrome) is a rare clinical entity. This disorder was first described in 1910 by Henry Meige as "spasm facial median," a disabling spasm of the facial musculature which had frequently been misdiagnosed and inappropriately treated. This report concerns a patient who presented with tonic hemifacial spasm twenty-two years after contracting Bell's palsy. The condition was initially thought to be secondary to faulty regeneration of the facial nerve until Meige's syndrome became fully manifested over a period of two years. The diagnostic characteristics as well as the forms of treatment for this unusual disorder are presented.

Blepharospasm associated with brainstem lesions

We studied six patients with clinical and radiographic evidence of rostral brainstem lesion and bilateral blepharospasm. Two patients also had other facial dystonic movements. Four patients suffered rostral brainstem strokes, and two had multiple sclerosis. None had been treated with antipsychotic drugs prior to the onset of blepharospasm. Medical treatment was helpful in two patients, and bilateral selective facial nerve section was used in another patient. Possible pathogenic mechanisms are discussed.