Sympathetic overactivity in the development of eyelid retraction in a patient with euthyroid Graves' disease evaluated by accommodation

It is known that measurement of accommodation is useful to evaluate the sympathetic activity of intraocular muscles. To find if sympathetic overactivity is involved in eyelid retraction in euthyroid Graves' disease, we measured accommodation in two patients with this disease, whose serum concentrations of free T3, free T4 and TSH were within reference ranges. Accommodation was measured with a computer-assisted infrared optometer with an iriscoder, and the results were expressed as the change in the eye's refractive power (in diopters) in response to the movement of a target beam. In patient 1, the accommodation amplitude was low, indicating sympathetic overactivity. This amplitude rose to near the reference range when timolol maleate drops were used, and the eyelid retraction disappeared when guanethidine drops were given. During the use of guanethidine drops, accommodation remained normal. In patient 2, who had normal accommodation, eyelid retraction did not change with guanethidine administration, but improved with intravenous methylprednisolone pulse therapy. These two cases suggested that even in euthyroid Graves' disease, eyelid retraction is caused by sympathetic overactivity, and pulse therapy with methylprednisolone may be effective for eyelid retraction when guanethidine drops are not effective.

A clinically oriented video-based system for quantification of eyelid movements

A field-worthy system was developed to quantify the eyelid movements in clinical sites. The system consists of a home-use charge-coupled device video camera, a processing unit, and a personal computer. A white marker of 4-mm diameter and 30-mg weight is attached to the lower margin of the upper eyelid. The processing unit automatically detects the vertical displacement of the upper edge of the marker. One marker is attached to each eye so that the movements of the both eyelids are measured with one camera simultaneously. The measurement error of the system was evaluated in experiments on eight healthy subjects and eight patients with eyelid paralysis. The mean of the absolute error of peak amplitudes occurring in 2 min was 0.81 mm, with the worst error being +1.7 mm. The reproducibility of the mean peak amplitude measured on five consecutive days was within 1 mm. The mean peak amplitudes of both eyes were measured preoperatively and postoperatively for approximately three months for three patients who were operated on to remove vestibular schwannoma. The results demonstrated basic clinical utility of the system.

Preservation of the brainstem auditory evoked potential in non-convulsive status epilepticus

Brainstem auditory evoked potentials (BAEPs) were recorded from a patient simultaneously experiencing non-convulsive generalized status epilepticus (NGSE). Waves I, III and V were normal but all subsequent waves were absent. This finding indicates that structures within the brainstem adjacent to the generators for the BAEP are likely not affected by NGSE and also illustrates the resilient nature of the BAEP. This is the first report of the recording of an evoked potential during a naturally occurring generalized seizure.

The jaw-winking syndrome

The jaw-winking syndrome involves synkinesis of the pterygoid muscles and levator palpebrae superioris, where the eyelid retracts with mandibular movements. Its appearance in the adult may be associated with other pathology, and recognition in the neonate may allow for earlier recognition of any ophthalmological problems. As it is elicited by jaw movements, the oral health care provider may be the first to recognise the condition. This report describes the incidental finding of jaw-winking syndrome in a 22-year-old Asian man. Although he suffered no physical or psychological effects from the condition, he did have an associated, corrected, ophthalmological defect.

[Dissociation of voluntary eye closure--to keep the eyes closed and to blink--following right hemisphere stroke]

We report a case of a unique eye sign following right hemispheric infarction. This patient was a 78 year old right-handed woman. There was a history of a left hemispheric stroke 1 year previously. On admission, she showed left hemianopia, dysarthria, mild left central facial paresis, bilateral sensory deficit and quadriparesis which were marked on the left side. Babinski sign was elicited on the left. She did not have anosognosia or visual neglect. She had mild orofacial apraxia, but ideomotor and ideational apraxia was absent. There was no motor impersistence. Magnetic resonance imaging of the brain revealed a recent infarction in the territory of the right middle cerebral artery and an old infarction in the left tempro-parietal lobe. The patient could not open her eyelids to verbal command or voluntarily until about two weeks later, when she became able to open her eyes but showed difficulty keeping her left eye closed. She was aware of this problem and could repeat the command and comprehend what was requested to her. On verbal command to close the eyes, her right eye would be closed continuously and excessively and the left eye would only blink. When requested to blink, however, she could blink correctly without excessive eye closure. Spontaneous, reflex and voluntary blinking were normal. Her eyes were closed normally during sleep. Blepharospasm was not seen. The patient showed a striking dissociation between a failure to close her eyes continuously and a preserved ability to blink voluntarily. We suggest that her ability to contract palpebral portion of her left orbicularis oculi muscle is preserved. Regarding the mechanism of the voluntary eye closure system, separate control mechanisms should exist on closing eyes continuously and blinking.

Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea

PURPOSE

To describe the beneficial effects of treatment of obstructive sleep apnoea on the symptoms and signs of floppy eyelid syndrome.

METHOD

A case of sleep apnoea with associated floppy eyelid syndrome is reported.

RESULTS

A 32-year-old man presented with left floppy eyelid syndrome and a known diagnosis of obstructive sleep apnoea. He underwent treatment for 4 years with continuous positive airways pressure by mask during sleep and the symptoms and signs of his floppy eyelid syndrome disappeared.

CONCLUSION

Treatment of obstructive sleep apnoea may reverse the changes of floppy eyelid syndrome.

The effect of upper blepharoplasty on eyelid position when performed concomitantly with Müller muscle-conjunctival resection

PURPOSE

To determine the effect on eyelid elevation of excising excess skin, orbicularis oculi muscle, and herniated orbital fat and reconstructing the upper eyelid crease (blepharoplasty) concomitant with a Müller muscle-conjunctival resection.

METHODS

The charts of 202 patients who had undergone Müller muscle-conjunctival resection during an 8-year interval were reviewed. Three hundred forty-five eyelids were divided into two groups. Group 1 (n = 162) underwent a Müller muscle-conjunctival resection only, and group 2 (n = 183) had this procedure combined with excision of skin, orbicularis muscle, and herniated orbital fat with upper eyelid crease reconstruction. Each group was divided into three subgroups based on the amount of Müller muscle-conjunctival resection. Subgroup A had resection less than 7.75 mm; subgroup B, resection of 7.75 to 8.75 mm; and subgroup C, resection greater than 8.75 mm. The change in margin reflex distance-1 (MRD1) measurements of the upper eyelid levels (postoperative MRD1 minus preoperative MRD1) were calculated and compared between groups.

RESULTS

The mean (+/- standard deviation) change in MRD1 was, respectively, 2.3 +/-1.0 mm and 1.9+/-1.0 mm for groups 1A and 2A; 3.1+/-1.3 mm and 2.1+/-1.2 mm for groups 1B and 2B; and 3.4+/-1.2 mm and 2.8+/-1.3 for groups 1C and 2C.

CONCLUSIONS

Blepharoplasty performed concomitant with a Müller muscle-conjunctival resection reduced the anticipated postoperative eyelid elevation by as much as 1 mm. Surgeons who perform these procedures together should be aware that a larger Müller muscle-conjunctival resection may be required to obtain the desired increase in eyelid height postoperatively.

Frontalis suspension combined with blepharoplasty as an effective treatment for blepharospasm associated with apraxia of eyelid opening

PURPOSE

Essential blepharospasm can be associated with apraxia of eyelid opening and is characterized by the inability to initiate the act of eyelid elevation even after cessation of orbicularis spasms. Current therapies such as botulinum toxin injections, orbicularis resection, or neurectomy may be unsuccessful or have undesired side effects.

METHODS

Frontalis suspension was used to treat 13 consecutive patients with apraxia and blepharospasm during a 4-year interval. Follow-up ranged from 16 months to 55 months. To improve the aesthetic outcome, an upper blepharoplasty was done at the same time as the frontalis suspension in 7 cases.

RESULTS

Good or excellent functional results were obtained in 10 of 13 patients. In 6 of these patients, the spasm disappeared completely. Therapy was unsuccessful in 1 patient, and in 2 patients blepharospasm recurred after 9 months.

CONCLUSION

Patients with blepharospasm and apraxia of eyelid opening may benefit from a frontalis suspension operation, which can be considered minimally invasive and reversible.

Cerebellar cortex lesions prevent acquisition of conditioned eyelid responses

We have used aspiration and electrolytic lesions to investigate the contributions of cerebellar cortex to the acquisition and expression of conditioned eyelid responses. We show that lesions of the anterior lobe of rabbit cerebellar cortex disrupt the timing of previously learned conditioned eyelid responses. These short-latency responses were used as an indication that the cerebellar cortex was sufficiently damaged and that the underlying pathways necessary for the expression of responses were sufficiently intact to support responses. Rabbits were subsequently trained for 15 daily sessions using a new conditioned stimulus. Whereas rabbits in which lesions had no significant effect on response timing showed rapid acquisition of appropriately timed eyelid responses to the new conditioned stimulus, animals with lesions that disrupt timing showed no significant increases in either amplitude or probability of responses. Histological analysis suggests that damage to the anterior lobe of the cerebellar cortex is necessary and sufficient to abolish timing and prevent acquisition. These data indicate that the cerebellar cortex is necessary for the acquisition of conditioned eyelid responses and are consistent with the hypotheses that (1) eyelid conditioning results in plasticity in both the anterior lobe of the cerebellar cortex and in the anterior interpositus nucleus and (2) induction of plasticity in the interpositus requires intact input from the cerebellar cortex.

A novel mechanism for benign essential blepharospasm

PURPOSE

The purpose of this study is to test the hypothesis that the photophobia of benign essential blepharospasm (BEB) is caused by sympathetically maintained pain.

METHODS

Nineteen patients with photophobia and BEB were enrolled in an unblinded prospective treatment trial. The intervention was blockade of the superior sympathetic ganglion with local anesthetic. Outcome measures included the patient's subjective report of ocular surface dryness, foreign body sensation, and eyelid spasm. We also obtained video recordings of eyelid movements.

RESULTS

Of the 19 patients, 13 reported subjective improvement in BEB symptoms after cervical sympathetic blockade (CSB). Thirteen of 19 patients also had objective evidence of decreased light-induced eyelid spasm after CSB. Ocular surface disease was present in 18 of 19 patients.

CONCLUSION

These data support the hypothesis that in many patients with BEB there is a sympathetically maintained pain syndrome associated with external ocular disease. We speculate on a neurologic circuit that may explain these findings.

Analysis of the corneal reflex with air puff: normal controls and patient groups

Though there are several reports published about the corneal reflex elicited by different methods, a standardized electrophysiologic study with air puff in man has not been published. The aim of this study is to standardize the corneal reflex elicited by air puff to cornea. The authors studied the corneal reflex with air puff and direct touch by using a standardized method in patients with thalamic hemorrhage (n = 15), hemispheric infarction (n = 9), brainstem infarction (n = 9), multiple sclerosis (n = 12), and Bell's palsy (n = 12) and in normal control subjects (n = 21). The conventional blink reflex (BR) was also studied. The reflex responses were recorded from both orbicularis oculi muscles by air puff and direct touch to cornea in addition to the electrical stimulation of the supraorbital nerve. No statistical difference could be detected between the responses elicited by air puff or direct touch to cornea (P > 0.05). Corneal reflex responses were statistically different from the R2 response of the BR (P < 0.005). Because the responses elicited by direct touch and air puff to cornea are identical, air puff to cornea can be used confidently to study the corneal reflex.

Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery

OBJECTIVE

To assess the effect of blepharoptosis on patients' visual function and health-related quality of life and to determine what measures are associated with postsurgical change in functional status.

DESIGN

Prospective, observational case series.

PARTICIPANTS

One hundred patients with unilateral or bilateral blepharoptosis. INTERVENTION/MAIN OUTCOME MEASURES: Preoperative and postoperative upper eyelid position (i.e., margin reflex distance [MRD]) and superior visual field (SVF) height, as well as subjective visual function and health-related quality-of-life functional status before and after ptosis surgery.

RESULTS

There was a mean 30-point increase in functional index score after ptosis repair (P < 0.001). Lower (more ptotic) preoperative upper eyelid position and SVF (combined eye) were associated with greater change in functional index after surgery (r = -0.290, P = 0.007 and r = -0.39, P = 0.003, respectively). Preoperative visual field testing with manual lid elevation was not significantly correlated to the postoperative change in functional index (P > 0.100). The strongest correlation of postoperative functional index change was with the preoperative functional status (r = -0.79, P < 0.001).

CONCLUSIONS

Patients' functional status is reduced by blepharoptosis, and surgical repair results in measurable increase in health-related quality of life. Patients' self-reported preoperative functional impairment is most strongly associated with the degree of postsurgical functional improvement.

"Apraxia of eyelid opening" induced by levodopa therapy and apomorphine in atypical parkinsonism (possible progressive supranuclear palsy): a case report

We report a female patient in whom so-called apraxia of eyelid opening (AEO) developed after the onset of possible progressive supranuclear palsy (National Institute of Neurological Disorders and Stroke criteria) and the introduction of antiparkinsonian medications including levodopa. Although parkinsonian symptoms responded poorly to levodopa, AEO worsened after increasing levodopa dosage and disappeared when levodopa was discontinued. Later, a dose of apomorphine widely accepted for acute tests had no significant effect on limb motor activity but induced AEO. Overall, these observations are grounds for thinking that AEO developing in the course of parkinsonism may be either disease- or drug-related. The possibility of manipulating dopaminergic treatment should always be considered when dealing with AEO associated with parkinsonism.

Randomized prospective study of the influence of steroids on postoperative eye-opening after exploration of the orbital floor

OBJECTIVE

To find out if giving steroids reduces postoperative swelling in orbital surgery.

DESIGN

Prospective, randomized, double-blind trial.

SETTING

Regional unit, teaching hospital, UK.

SUBJECTS AND INTERVENTIONS

20 patients who require orbital floor exploration after injuries. Patients were given methylprednisolone 250 mg (or placebo identically packaged) at induction of anaesthesia, with a further three doses at 6-hourly intervals postoperatively.

MAIN OUTCOME MEASURE

Differences in interpalpebral width before and after operation.

RESULTS

Those given steroids (n=11) had a significantly increased interpalpebral width compared with placebo (n=9) postoperatively (P < 0.01, 95% confidence intervals of the difference = 1 mm-6 mm).

CONCLUSION

Short courses of steroids therapy should be considered in orbital surgery for appropriate patients. There is an advantage in being able to assess the globe postoperatively.

Eye closure related spike and wave discharges: clinical and syndromic associations

Precipitation of spike and wave (SW) discharges in some epileptic patients by eye closure (EC) has rarely been reported. To disclose the clinical characteristics and classification of syndromes of epileptic patients with SW discharges induced by EC, we investigated 10 patients (1 M, 9 F) showing this peculiar EEG feature. The patients aged between 9-39 years (mean 20.6 +/- 9.058), underwent short-term (1-3.5 hr) video-EEG investigations in order to document the appearance of the SW discharges within 3 seconds of the act of EC, in at least two occasions. Clinical analysis showed that 5 female patients who had the syndrome of juvenile myoclonic epilepsy (JME) had a later onset of epilepsy (13-15 years) than the 3 patients (3 girls) with eyelid myoclonia with absences (EMA) (3-8 years of age at onset). The remaining 2 patients who were diagnosed as childhood absence epilepsy (CAE) and juvenile absence epilepsy (JAE) according to the international classification, did not show photosensitivity on the video-EEG. All but one of the 5 JME patients had experienced myoclonic seizures in intermittent photic stimulation (IPS) at the time of EC, associated with multiple spike and wave discharges. Two of the 3 EMA patients exhibited typical absences with eyelid myoclonia during the act of EC. The high rate of family history of epilepsy in first degree relatives of our patients was an outstanding feature, which could have future implications in research of the genetic basis of epilepsy patients with ECS.

Blepharospasm and apraxia of eyelid opening in lithium intoxication

We present the case of a 72-year-old woman with a history of a bipolar mood disorder chronically treated with lithium. Upon having the dose increased, she developed an acute confusional state accompanied by blepharospasm (BS) and apraxia of eyelid opening. Gait instability with frequent falls, pyramid tract signs, and postural tremor in both hands were also evident. On withdrawing lithium, symptoms remitted within 2 weeks. This patient illustrates that BS and apraxia of eyelid opening may be triggered by lithium overdose. Our case warrants the inclusion of lithium in the list of drugs liable to induce such movement disorders.

Stabilization of eyelid height after aponeurotic ptosis repair

OBJECTIVE

To develop guidelines for revision of ptosis surgery in the early postoperative period by establishing what percentage of eyelids after anterior levator advancement have reached their final height by the first postoperative week.

DESIGN

Prospective noncomparative case series.

PARTICIPANTS

An analysis was performed on 164 eyelids in 97 patients with involutional aponeurotic ptosis.

INTERVENTION

Anterior levator advancement was performed on each of these 164 eyelids. Exclusion criterion consisted of a history or evidence of neurologic or muscular disease, preceding trauma, an anophthalmic socket, or prior eyelid surgery.

MAIN OUTCOME MEASURES

The marginal reflex distance, eyelid excursion, and degree of swelling were recorded perioperatively; additionally, photographs were obtained before surgery and at 1 and 6 weeks after surgery.

RESULTS

At 1 week after surgery, only 40% of eyelids had reached their final height; 52% continued to rise a mean of 1.1 mm. The percentage of eyelids continuing to rise after the first postoperative week varied with the amount of swelling present at 1 week, although a direct correlation did not exist (Pearson correlation, 0.22; P < 0.26). Although this increase ranged from 0.5 to 3.0 mm for 71% of eyelids, the subsequent increase was 1 mm or less. Maximal eyelid height was achieved almost universally by 6 weeks, after which 18% of eyelids subsequently dropped a mean of 0.8 mm.

CONCLUSIONS

Based on this study, the authors suggest revision at 1 week after anterior levator advancements in which minimal-to-moderate eyelid swelling exists for contour abnormalities, if the eyelid height is 0.5 mm or more above or more than 1.0 mm below the target height, or if asymmetry between the eyelids is 1.0 mm or more. The authors do not advise early revision for patients with excessive swelling still present 1 week after surgery.

Electrical stimulation as a therapeutic option to improve eyelid function in chronic facial nerve disorders

PURPOSE

To establish whether it is possible to improve orbicularis oculi muscle function in the eyelids of patients with a chronic seventh cranial nerve palsy by using transcutaneous electrical stimulation to the point at which electrical stimulation induces a functional blink.

METHODS

Ten subjects (one woman, nine men) aged 36 to 76 with chronic, moderate to severe facial nerve palsy were recruited into the study. Voluntary and spontaneous eyelid movements were assessed, using an optical measuring system, before, during, and after a 3-month treatment period. Voluntary and spontaneous lid velocities were also measured and compared with eyelid kinematic data in normal subjects (12 women, 18 men; age range, 22-56 years).

RESULTS

Therapeutic electrical stimulation applied over 3 months produced improvement in eyelid movement (>2 mm) in 8 of 10 patients during voluntary eyelid closure. However, there was no significant improvement recorded in spontaneous blink amplitudes or peak downward-phase velocity of the upper eyelid. This regimen of stimulation failed to recover function well enough that a functional blink could be induced in the paretic eyelid by electrical stimulation.

CONCLUSIONS

Electrical stimulation using transcutaneous electrical nerve stimulators units can improve voluntary eye closure, apparently because of a reduction in stiffness of eyelid mechanics, rather than an improvement of muscle function. Investigation of alternative stimulation regimens is warranted.

Hemifacial spasm: clinical findings and treatment

Hemifacial spasm (HFS) is a peripherally induced movement disorder characterized by involuntary, unilateral, intermittent, irregular, tonic or clonic contractions of muscles innervated by the ipsilateral facial nerve. We reviewed the clinical features and response to different treatments in 158 patients (61% women) with HFS evaluated at our Movement Disorders Clinic. The mean age at onset was 48.5+/-14.1 years (range: 15-87) and the mean duration of symptoms was 11.4+/-8.5 (range: 0.5-53) years. The left side was affected in 56% instances; 5 patients had bilateral HFS. The lower lid was the most common site of the initial involvement followed by cheek and perioral region. Involuntary eye closure which interfered with vision and social embarrassment were the most common complaints. HFS was associated with trigeminal neuralgia in 5.1% of the cases and 5.7% had prior history of Bell's palsy. Although vascular abnormalities, facial nerve injury, and intracranial tumor were responsible for symptoms in some patients, most patients had no apparent etiology. Botulinum toxin type A (BTX-A) injections, used in 110 patients, provided marked to moderate improvement in 95% of patients. Seven of the 25 (28%) patients who had microvascular decompression reported permanent complications and the HFS recurred in 5 (20%). Although occasionally troublesome, HFS is generally a benign disorder that can be treated effectively with either BTX-A or microvascular decompression.

Efficacy of gold weight implants in facial nerve palsy: quantitative alterations in blinking

Deficient eyelid closure is a major visual threat to patients with unresolved facial nerve palsy. Gold weight implants assisted eyelid closure in patients with paresis of the orbicularis oculi, ameliorating patient complaints of dry eye, excessive tearing, and corneal epithelial breakdown. We used dynamic measures to assess the efficacy of upper eyelid gold weight implantation surgery for facial nerve palsy. The search coil technique was used to record spontaneous blinks bilaterally in six patients, before and after unilateral gold weight implantations into the upper eyelid in severe facial nerve palsy. In uncomplicated facial nerve palsy, the amplitude of blink down-phases for the paretic eyelid was 28.6 +/- 5.7% of the amplitude of the contralateral, normal eyelid. Following corrective surgery, closure of the paretic eyelid improved to 42.6 +/- 7.5% (P < 0.05). There was not a commensurate increase in the peak velocity of blink down-phases, suggesting that gold weight effects are mediated by a passive improvement in blink dynamics.