Complications in surgery for blepharospasm

Botulinum toxin for benign essential blepharospasm: A systematic review and an algorithmic approach

BACKGROUND

Currently, there is no standardised approach for benign essential blepharospasm treatment with botulinum toxin, and controversies still exist regarding this subject.

OBJECTIVE

The objective of this systematic review is to summarise and compare all the published data regarding benign essential blepharospasm treatment with botulinum toxin.

METHODS

On October 3, 2018, an online search of the Medline database was conducted. All articles with a detailed description of their botulinum toxin injection technique for benign essential blepharospasm were included in this review.

RESULTS

Five studies were selected for inclusion with a total of 854 patients. Four of the included studies used onabotulinumtoxin A and one study used abobotulinumtoxin A. All studies injected the pretarsal orbicularis occuli muscle. The preseptal orbicularis occuli was injected in four studies, and the preorbital muscle in three studies. The most commonly used method of evaluation was the Jankovic Rating Scale. Adverse events were transient, and dose related. Ptosis was more frequently encountered with the preseptal orbicularis injections.

CONCLUSION

Botulinum toxin injection for benign essential blepharospasm is a non-invasive and safe procedure. The pretarsal muscle should be considered as the key component when treating benign essential blepharospasm with botulinum toxin. We developed an algorithmic approach to the treatment of benign essential blepharospasm with botulinum toxin. However, further randomised controlled trials are warranted.

SURGICAL ASPECT OF BLEPHAROSPASM TREATMENT: A CASE REPORT

Blepharospasm is an idiopathic condition characterized by involuntary eyelid closure mainly caused by bilateral tonic-clonic contractions of the orbicularis oculi muscle. It results in patient inability to open their eyes, thus significantly impairing their ability to perform activities of daily living. First-line treatment for blepharospasm are primarily botulinum toxin type A injections. However, surgical procedure as a treatment option can also be taken in consideration. In this overview, we present a case of a 75-year-old female patient who received surgical treatment as per Anderson's method after being treated with botulinum toxin type A for 3 years. This form of therapy proved to be an extremely successful permanent solution in the treatment of severe cases of refractory blepharospasm, without any long-term complications, especially ectropion and lagophthalmos.

Clinical outcomes of individualized botulinum neurotoxin type A injection techniques in patients with essential blepharospasm

Purpose

To assess the clinical outcomes following botulinum neurotoxin type A (BoNT-A) treatment with an individualized injection technique based on the types of spasms and to compare the results of the individualized injection technique with those of the conventional injection technique in the same patients.

Methods

From November 2011 to July 2013, 77 BoNT-A injections were performed in 38 patients. Eighteen patients were treated with conventional BoNT-A injections before 2011, and 20 patients were referred to our hospital for unsatisfactory results after a conventional injection technique. We classified the patients by spasm-dominant sites: the lateral orbital area, representing the orbital orbicularis-dominant group (ODG); the glabella, representing the corrugator-dominant group (CDG); and the ptosis, representing the palpebral part of the orbicularis-dominant group (PDG). We increased the injection dose into the spasm-dominant sites of the blepharospasm groups. We assessed subjective symptom scores (functional disability score, FDS) after treatment.

Results

This study included 38 patients (26 women, 12 men; mean age, 60.6 ± 10.9 years). There were 21 patients in the ODG, 10 patients in the CDG, and 7 patients in the PDG. Mean ages were 59.7 ± 12.6, 59.8 ± 8.5, and 66.8 ± 9.0 years, and mean BoNT-A injection dose was 38.8 ± 11.2, 38.8 ± 11.2, and 38.8 ± 10.8 U in each group, respectively (p = 0.44, 0.82 Kruskal-Wallis test). Mean FDS after injection was 1.7 ± 0.7 in the ODG, 1.4 ± 0.8 in the CDG, and 1.2 ± 0.3 in the PDG. There were significant differences in reading and job scale among the three groups. In a comparison between the conventional and individualized injection techniques, there was a significant improvement in mean FDS and in the reading scale in the PDG with the individualized injection technique. The success rate was 92.1% in the conventional injection group and 94.1% in the individualized injection group.

Conclusions

The individualized injection technique of BoNT-A according to the spasm-dominant site is an effective and safe treatment method for essential blepharospasm patients.

Anatomy of the Supraorbital Region and the Evaluation of it for the Reconstruction of Facial Defects

Damaged supraorbital neurovascular bundle during anterior orbital approach, fronto-glabellar reconstruction flap, supraorbital injection, blepharospasm, and Graves disease surgery is an important complication reported with varying frequency. The origin, calibration, and branches of the supraorbital artery and its topographical relations were investigated by injection of the arterial bed with red-dyed latex in 38 forehead regions. The supraorbital artery with the supratrochlear artery arose from the orbit as two separate vessels in 33 out of 38 forehead sides (87%). The supraorbital artery entered the frontalis muscle between 20 and 30 mm in 20 cases (52.6%), and between 30 and 40 mm in 16 cases (42.1%). This artery was located approximately the subcutaneous tissues between 40 and 50 mm in 17 cases (44.7%), between 50 and 60 mm in 18 cases (47.4%). The transverse supraorbital vein coursed at the level of the orbital rim on 22 sides (58%) and between 6.1 and 11.2 mm (mean: 9.4 mm) above the supraorbital rim on 16 sides (42%). All branches of supraorbital nerve were located between 2.0 and 3.2 cm from the midline at the level of the orbital rim. In 23 cases (60%), the lateral branch of the supraorbital nerve exited the bone as two branches, usually one large and one much smaller, which can together run into the scalp without further branching. In the present anatomical study, special attention was paid to morphological details concerning the neurovascular relationship of the supraorbital region. A better understanding of the midline forehead neurovascularity should allow modification of reconstructive techniques, afford better localization of the supraorbital nerve during blepharoplasty and ptosis surgery, and reduce the incidence of postoperative hematomas and nerve injuries.

Orbicularis oculi muscle graft augmentation after protractor myectomy in blepharospasm

PURPOSE

To evaluate the effectiveness of free orbicularis oculi muscle grafts in correcting volume deficit deformities after protractor myectomy in patients with essential blepharospasm.

METHODS

Prospective case series. During the 13-month period from October 2000 through November 2001, all patients with essential blepharospasm undergoing primary eyelid protractor myectomy received an orbicularis oculi muscle graft to replace the volume deficit deformity created by the myectomy. Only patients who had at least 6 months of postoperative follow-up were included in the analysis.

RESULTS

Forty-six patients underwent primary eyelid protractor myectomy and had a free orbicularis oculi muscle graft for volume replacement. All patients had significant functional improvement of their eyelid spasms after the myectomy. Of the 38 patients who underwent upper eyelid myectomy, 3 patients were overcorrected and no patients were undercorrected with the orbicularis muscle graft. Two of the overcorrected patients underwent surgical debulking of their muscle grafts. Of the 8 patients who underwent lower eyelid myectomy, no patients were overcorrected and 1 patient was undercorrected. None of the patients were observed to have any spasms, contractions, or other signs of muscular activity or aberrant innervation of the muscle graft.

CONCLUSIONS

The orbicularis oculi muscle graft is a useful adjunct to protractor myectomy in improving the aesthetic outcomes for blepharospasm patients. Our study demonstrates the viability of the orbicularis oculi muscle graft and may lead to future applications of the graft in facial aesthetics.

Superselective neurectomy with periorbital primary reconstruction for blepharospasm. Case report

A 66-year old man with blepharospasm and ptosis of the brow was treated with a combined procedure in which the branches of the facial nerve were excised at the margin of the orbicularis, and the periorbital area was reconstructed simultaneously. The condition improved after the treatment with no occurrence of either oral complications or facial anaesthesia.

Anatomical reasons for problems after neurectomy for blepharospasm: a study in cadavers

The purpose of this study is to clarify the mechanisms of the problems that develop after neurectomy for blepharospasm. The left facial nerves in 10 Japanese cadavers were dissected under a surgical microscope. The temporal, zygomatic, and buccal branches innervated to the orbicularis oculi muscle. These three groups formed a well-communicating plexus posterior to the orbicularis. The most inferior buccal branch curved in the deep layer in the lower part of the cheek. In the cheek, both the buccal and the temporal branches had ramifications of other facial muscles. The information given in previous anatomical textbooks did not specifically define the denervation of the orbicularis. When neurectomy was done in the past, the inferior buccal branch may have been kept intact, or other facial muscles as well as the orbicularis may have been denervated which caused the blepharospasm to recur and complications to develop after neurectomy.

Anatomic study of the distal supraorbital nerve

This investigation was designed to extend our present knowledge of the supraorbital n. (SO n.) distal to the supraorbital notch. It is based on 40 dissected hemi-faces and the position of the notch and the periosteal and frontalis cutaneous branches of the SO n. were studied. The notch was 33.05 mm from the midline on the right side and 30.70 mm on the left. The periosteal branch arises from the lateral frontalis cutaneous branch. Its ascends in an oblique direction laterally and ends in two terminal branches. The frontalis cutaneous branch, after a very short trunk, divides into two branches, medial and lateral. The medial or deep branch enters the corrugator supercilii m. between its fibers. Most frequently, it passes under the inferior fasciculus and superficial to the middle and superior ones. Leaving the corrugator m., it ascends medially into the frontalis m., supplying the median cutaneous frontalis region. The lateral or superficial branch crosses superficial to the corrugator supercilii m. to penetrate the frontalis m. in an ascending and lateral direction, supplying the lateral frontalis region. The two branches enter the frontalis m., displaying a zigzag pattern in order to adapt its length during expressive movements. They cross the frontalis region together with the SO a. and two veins supplying the nerve and the frontalis m. These anatomic data may explain some of the complications after surgery for ptosis and blepharospasm.

The use of botulinum toxin for treatment of acquired nystagmus and oscillopsia

PURPOSE

To evaluate the role of botulinum toxin A (BTA) in treating patients with diminished visual acuity secondary to acquired nystagmus and oscillopsia.

METHODS

Twelve patients with acquired nystagmus causing oscillopsia and reduced vision were treated with injection of BTA. Botulinum toxin A was injected directly into the horizontal recti in three patients, and in nine patients retrobulbar BTA was administered. Injections were given at 3- to 4-month intervals and repeated as long as patients noted improvement in their quality of life.

RESULTS

Improvement in visual function varied, and not all patients benefited from the procedure. However, 8 of 12 patients demonstrated a measurable improvement in visual acuity. Transient ptosis was the most common side effect.

CONCLUSION

Retrobulbar BTA provides a simple and safe alternative in managing a condition for which alternative treatments are typically unsatisfactory.

Vertically oriented upper eyelid nerve fibers. A clinical, anatomical and immunohistochemical study

Vertically oriented suborbicular nerve fibers are frequently encountered during upper eyelid surgery. It has not been well established whether these fibers are terminal motor branches of the facial nerve (VII) or sensory branches of the ophthalmic nerve (V-1). To investigate the origin of these nerve fibers, three different techniques were used: (1) intraoperative nerve stimulation; (2) cadaver dissection; and (3) immunohistochemical analysis. The results of all three investigative methods are in agreement and conclusively demonstrate that these fibers represent sensory branches of the ophthalmic nerve (V-1) and not motor branches of the facial nerve (VII). Anatomical dissection showed that the sensory fibers to the upper eyelid do not travel solely within the suborbicular fascial plane, but also course in the preorbicular plane and within the orbicularis muscle itself. The terminal branches of the facial nerve to the upper eyelid innervate the orbicularis oculi from the undersurface and in a horizontal orientation. Clinical correlation of these findings is discussed.

Surgical management of essential blepharospasm

We have reviewed the surgical management of essential blepharospasm over the last 15 years, comparing the results from facial nerve avulsion with those from orbicularis muscle stripping. After facial nerve avulsion 50% of patients remained free of troublesome spasm for 15 months after surgery, but only 25% remained so for more than two years. Following orbicularis oculi myectomy 50% of patients were free of troublesome spasms for 30 months after surgery and 55% of patients had relief from spasm for more than two years. Secondary effects of the two procedures are compared and are found to be fewer after orbicularis myectomy. There were no major complications after either form of surgery. Botulinum toxin is the treatment of first choice for this condition. If this becomes ineffective or inconvenient, surgical treatment is warranted and should not be deferred for fear of severe side effects of treatment, since these are rare. Protractor myectomy gives longer relief from blepharospasm than facial nerve avulsion and has fewer complications. However, it is technically difficult, time consuming, and has greater peroperative morbidity. Facial nerve avulsion may therefore still have a role in selected patients.

Treatment of facial spasm with Oculinum (C. botulinum toxin)

Forty-six consecutive adult patients with facial spasm were treated with one or more Botulinum toxin (Oculinum) injections to control muscle spasm. During the follow-up period of 6.6 months (one week-12 months), 27 patients required retreatment with a mean time interval of 3.4 months between treatments. Control of facial spasm was achieved in all patients. Complications included occasional bruising around the injection site and a transient blepharoptosis in one patient. No systemic effect was observed. This preliminary report suggests that treatment with Botulinum toxin (Oculinum) is an acceptable alternative to surgical management in select patients.

Effect of treatment with botulinum toxin on neurogenic blepharospasm

Botulinum toxin type A creates temporary localised flaccid paralysis after injection into skeletal muscle. Thirty four patients with blepharospasm, of whom 28 also had the oromandibular dystonia syndrome, were treated with injections of botulinum toxin type A into the orbicularis oculi, and 28 showed functional improvement after the treatment. A high incidence of local side effects occurred, especially partial ptosis, which was well tolerated. There were no systemic side effects. The average period of relief was 2.5 months, increasing to 2.8 months after a second injection. Functional improvement was limited in patients with severe associated dystonia.

Parotid duct injury as a complication of differential seventh nerve ablation

A 68-year-old man with intermittent blepharospasm complained of pain and induration after undergoing differential ablation of the seventh nerve. Because radiation therapy was ineffective, we inserted a 5-mm silicone tube into a serous cyst in the parotid gland. The induration subsided and the patient's recovery was uneventful.