Botulinum toxin injections for the treatment of hemifacial spasm over 16 years

Preseptal and Pretarsal Botulinum Toxin Injection in Hemifacial Spasm and Blepharospasm: A 10-Year Comparative Study

Purpose

Preseptal and pretarsal botulinum toxin injections are approved for treatment of hemifacial spasm and blepharospasm. However, the long-term data is limited. We compared the efficacy, safety, and costs between preseptal and pretarsal injection in hemifacial spasm and blepharospasm.

Patients and Methods

The data were retrieved between 2011 and 2021. Consecutive hemifacial spasm and blepharospasm botulinum toxin patients were categorized as preseptal or pretarsal. Study outcomes were the difference in pre-and post-treatment modified Jankovic scale, self-reporting scales, time-related treatment, safety, and cost.

Results

Of 152 botulinum toxin-injected patients, 117 (77.0%) patients had hemifacial spasm and 35 (33.0%) patients had blepharospasm. Analysis included data pertinent to 1665 injections in hemifacial spasm (920 preseptal and 745 pretarsal) and 527 injections in blepharospasm (210 preseptal and 317 pretarsal). The difference between pre-and post-treatment modified Jankovic scale was lower in the preseptal group than in the pretarsal group in both hemifacial spasm and blepharospasm (1.5±0.8 vs 1.8±0.6, P-value <0.001 and 1.8±0.8 vs 3.1±0.9, P-value <0.001). There was no difference in duration of maximum response in hemifacial spasm between groups, while the blepharospasm with preseptal had a longer duration than blepharospasm with pretarsal. The preseptal injection was associated with more adverse events overall than the pretarsal (9.4% vs 5.2%, P-value <0.001). The total dose and cost per session in the preseptal group is lower for onabotulinum toxin but higher for abobotulinum toxin.

Conclusion

Pretarsal injections reduced symptom severity with fewer side effects. Further studies on the pharmacoeconomics of both techniques are required.

Therapeutic Approach to Botulinum Injections for Hemifacial Spasm, Synkinesis and Blepharospasm

The aim of this study was to show our therapeutic outcome of botulinum injection to the facial muscles and thereby to find the best therapeutic concept which should be embraced. The decision to treat the lower eyelid with 1-point or 2-points injection was randomly taken as there is no consensus regarding this debate. Injections of the lateral end of the upper eyelid were performed more laterally to the conventional injection point, just lateral to the conjunction of the upper and lower eyelids. Twenty-three patients (12 hemifacial spasm, 6 blepharospasm, 5 post facial palsy synkinesis) were enrolled. Data were retrieved from 112 visits between 2019 and 2022. Overall, 84.9% of the treatments had moderate or marked improvement. The most common side effect was facial weakness (11.8%). Neither ptosis nor diplopia were noted. Two-points regimen in the lower eyelid was associated with a lower risk of facial weakness (p = 0.01), compared to 1-point regimen, with a better therapeutic outcome as reflected by more favorable PGI-C scores (p = 0.04). Injection of the pretarsal segment of the upper eyelid, just onto or even lateral to the conjunction of the upper and lower eyelids, lowers the risk of ptosis.

Complications of Preseptal Versus Pretarsal Botulinum Toxin Injection in Benign Essential Blepharospasm: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to compare ocular complications and efficacy of preseptal (PST) versus those of pretarsal (PTS) botulinum toxin type A (BoNT-A) therapy in cases of benign essential blepharospasm (BEB).

DESIGN

Randomized clinical trial.

METHODS

Setting: university hospital.

PATIENTS

24 participants with BEB were enrolled from August 2019 to June 2020. All patients and the outcome evaluator were masked to the injection allocation.

INTERVENTIONS

for each participant, 1 eye was randomized to receive PST BoNT-A injection, and the fellow eye received PTS BoNT-A injection of the same amount from a single investigator. At baseline, 1, and 3 months after the injection, we collected the symptoms of tearing, lagophthalmos, ptosis, and diplopia and measured margin-to-reflex distance (MRD) 1 and 2 (mm), degree of lagophthalmos (mm), presence of ectropion, entropion, limitation of ocular motility, tear film breakup time (second), Schirmer's test (mm) , ocular surface staining scores (Oxford's scheme), and Jankovic rating scale of both eyes separately. Main outcome measurements were complications of the injection.

RESULTS

There were statistically significant higher rates of self-reported lagophthalmos in PTS (n = 12; 52.17%) than in PST (n = 7; 30.43%) BoNT-A injections (P = .024) and significantly higher estimated measurements of lagophthalmos in PTS (0.59 mm; 95% confidence interval [CI]: 0.44-0.72) than in PST (0.26 mm; 95% CI: 0.12-0.40) injection at 1 month using an interaction model (Bonferroni-corrected P = .001). No significant differences in the efficacy and other complication outcomes between the injection locations were observed.

CONCLUSIONS

PTS BoNT-A injection had a higher rate of lagophthalmos than PST BoNT-A injection for BEB.

Dry Eye Disease in Hemifacial Spasm Patients Treated with Botulinum Toxin Type A

Purpose

To assess the impact of botulinum toxin type A (BTX-A) on signs and symptoms of dry eye (DE) in affected eye of hemifacial spasm (HFS) patients and to compare the prevalence of DE between affected and non-affected eye in HFS patients.

Patients and Methods

This prospective study included participants with unilateral HFS, who received BTX-A injection as a treatment. The eyes ipsilateral to the spasm side were used as studied eyes and the contralateral eyes were used as controls. The Ocular Surface Disease Index (OSDI) score, tear break-up time (TBUT), corneal fluorescein staining, and Schirmer I test were measured at baseline, 1 and 3 months after BTX-A injection. Fluorescein clearance test (FCT) was evaluated at baseline and at 1 month after BTX-A injection.

Results

Thirty-one participants (6 males and 25 females; mean age 61±10 years) were included. The prevalence of DE according to the Asia Dry Eye Society was not significantly different between affected (37.93%) and non-affected eyes (27.6%); P=0.083. At baseline, there was no significant difference in TBUT, Schirmer test, basal tear secretion, presence of delayed tear clearance, and presence of reflex tear secretion between affected and non-affected eyes, while significant difference in Oxford scheme grade was observed (P=0.031). OSDI score, TBUT, Oxford scheme grade, and Schirmer test at 1 month (P=0.817, 0.796, 0.534, 0.556), and 3 months (P=0.803, 0.904, 0.936, 0.684) after BTX-A injection did not significantly change from baseline in affected eyes. FCT results were not significantly different between baseline and at 1-month follow-up in both groups. All findings were corresponding in both naïve and long-term botulinum toxin injection groups.

Conclusion

We found no significant effect of BTX-A on signs and symptoms of DE in patients with HFS. Moreover, there was no significant association between HFS and DE. However, we found significant corneal surface damage in the affected eyes, which emphasized importance of ocular surface evaluation and prompt treatment in HFS patients.

Real-world experience with botulinum toxin A for the treatment of hemifacial spasm: A study of 1138 injections

BACKGROUND

Hemifacial spasm (HFS) is a chronic, potentially disabling disorder that often requires long-term management with botulinum toxin (BoNT). In a country where healthcare costs limit compliance to medical follow-up and treatment, the study aims to provide a real-world experience on the use of BoNT for HFS among Filipinos.

METHODS

We retrospectively collected data from 162 HFS patients who received 1138 botulinum toxin (BoNT) injections from 2006 to 2019 in our movement disorders center in the Philippines. We described their clinical profile and treatment response.

RESULTS

The mean age at onset of disease was 47.7 ± 10.72 years. Majority of the patients reported a baseline moderate disease severity and disease frequency of >75% of waking time (59.8% and 46.9%, respectively). Most patients (61.73%) received 5 or less injections during the follow-up period. The mean duration of follow-up was 2.96 ± 4.28 years. The overall duration of treatment effect per injection was 3.6 ± 1.3 months while the mean interval between injections was 6 ± 5 months. There was no difference in the symptom improvement and duration between onabotulinumtoxinA and abobotulinumtoxinA. Side effects were infrequent.

CONCLUSION

This study supports existing evidence on the efficacy and safety of BoNT for the symptomatic relief of HFS. In the Philippines, long-term treatment with BoNT may be limited by the cost of the procedure as majority of our patients had a few injections with long treatment intervals.

Hemifacial spasm through the last three decades: From etiology to efficacy and safety of long-term botulinum toxin treatment

BACKGROUND

Hemifacial spasm (HFS) is an uncommon movement disorder characterized by involuntary contractions of muscles innervated by the facial nerve. The aim of this study is to analyze the etiology of HFS as well as the efficacy and safety of long-term botulinum toxin type A (BTX-A) treatment.

METHODS

Retrospective study including 125 patients with HFS treated with BTX-A from 1993 to 2019. Demographic and etiological variables as well as doses, number of sessions of BTX-A, infiltrated muscles, therapeutic response according to Patient Global Impression of Change Scale (PGIC-S), side effects and adjuvant treatments were analyzed. In addition, these variables were compared according to the etiology (idiopathic versus secondary).

RESULTS

92 patients (73.6%) were women and the mean age at diagnosis was 58.63 years (SD 15.4). The etiology was idiopathic in 79 patients (63.2%), 17.6% were secondary to Bell's palsy, 14.4% to vascular compression and 2.4% to tumors. A higher total dose per session was observed in the secondary group. PGIC-S showed a good response in 96% of cases. 16 patients (12.8%) required pharmacological concomitant treatment. 59 patients (47.2%) developed side effects. Transient eyelid ptosis and facial weakness were the most common.

CONCLUSIONS

The structural origin of a significant number of cases of HFS makes essential to complete an etiological diagnosis in all patients. In addition, the existence of a secondary cause could be associated with greater doses of BTX-A to achieve a good response. Regardless the etiology, long-term treatment with BTX-A in HFS is safe and effective.

[Hemifacial spasm]

Hemifacial spasm (HFS), or facial hemispasm, is a paroxysmal hyperkinetic disorder involving muscles innervated by the facial nerve, mainly on the one hand. The development of HFS is based on neurovascular conflict. However, it is impossible to explain the clinical manifestations of HFS only by nerve compression. Both peripheral and central mechanisms are involved in the generation of HFS, with the formation of ephaptic transmission, antidromic excitation, primary or secondary hyper-excitability of the nuclear and supranuclear level of innervation. Two treatment methods are pathogenetically justified: microvascular decompression (MVD) and botulinum toxin (BTX) injections. The effectiveness of MVD is 95.37% with full or partial recovery. The recurrence rate does not exceed 2.4%. Facial nerve paralysis (2.7-22.5%) and hearing loss (1.9-20%) are the most common complications of treatment with the use of the MVD for HFS with partial or complete cure in most cases. Botulinum toxin injection chemo-denervation is a first-line treatment of primary and secondary HFS. HFS is an officially registered indication for the drug dysport (abobotulotoxin) (ABO) in the Russian Federation. Total doses of ABO ranged from 25 to 150 units for one side depending on the severity of the clinical manifestations. Studies demonstrate the statistically significant benefits of HFC treatment with ABO. ABO is generally well-tolerated. Adverse events (up to 3.6%) are transient and include ptosis, lacrimation, blurred vision, double vision, dry eyes and weak facial muscles.

Endoscopic assisted microvascular decompression versus new antiepileptics and BOTOX in treatment of hemifacial spasm: a clinical trial

Introduction

Hemifacial spasm (HFS) is a chronic movement disorder characterized by twitching of muscles of facial expression which is innervated by the facial nerve. The condition is unilaterally, beginning in the orbicularis occuli, and later on progress to involve the perioral, platysma, and other muscles of facial expression. Endoscopic assisted microvascular decompression is considered the state of the art in hemi-facial spasm surgery. New antiepileptic have emerged with a new hope for good control with few side effects. Botulinum toxin is still a good option for some patients.

Methods

This study is a prospective study that was conducted on 30 patients with primary hemifacial spasm. Bilateral and secondary cases where excluded. All patients were subjected to proper pre-treatment assessment including; proper history taking, clinical examination, and proper radiological investigations (MRI, FISTA) when needed. They were divided into three groups according to treatment modality: group A where patient's general condition was unfit for surgical intervention, received oral medications (gabapentin or levetiracetam); group B included those patients unfit for surgical intervention and did not respond to oral therapy, received Botox injection; and group C underwent endoscopic assisted microvascular decompression. Follow-up period ranged from 6 to 24 months. Outcome of different treatment modalities were compared among different groups.

Results

Among group A patients, one patient showed excellent response to treatment (Gabapentin 1200 mg), three patients had good response, four patients had fair response, and three patients had poor response to treatment (one used levetiracetam, two used gabapentin). Overall success rate is 72.7%. Among group B patients, four patients enjoyed excellent response. Another four patients had good response, while three patients had fair response. Only one patient had poor response. Overall success rate was 83.3%. Among group C patients, five cases had excellent outcome and two cases had good outcome. Overall success rate is 100%.

Conclusion

Endoscopic assisted microvascular decompression offers the best chance to permanent cure with low complication rate. New antiepileptics (levetiracetam, gabapentin) provide a safe therapy for patients refusing surgical intervention. Botox is an attractive local therapy with reversible complications but with non-sustainable effect. From our results, we conclude that endoscopic assisted microvascular decompression is superior to either BOTOX or antiepiletics for the permanent cure of hemifacial spasm.

Treatment of Blepharospasm/Hemifacial Spasm

OPINION STATEMENT

The treatment of both hemifacial spasm (HFS) and blepharospasm (BEB) requires making the appropriate clinical diagnosis. Advance imaging and electrophysiologic studies are useful; however, one's clinical suspicion is paramount. The purpose of this review is to summarize current and emerging therapies for both entities. Botulinum toxin (BTX) remains the first-line therapy to treat both conditions. If chemodenervation has failed, surgery may be considered. Due to the risks associated with surgery, the benefits of this option must be carefully weighed. Better surgical outcomes are possible when procedures are performed at tertiary centers with experienced surgeons and advanced imaging techniques. Microvascular decompression is an efficacious method to treat HFS, and myectomy is an option for medication-refractory BEB; the risks of the latter may outweigh any meaningful clinical benefits. Oral agents only provide short-term relief and can cause several unwanted effects; they are reserved for patients who cannot receive BTX and/or surgery. Transcranial magnetic stimulation has gained some traction in the treatment of BEB and may provide safer non-invasive options for refractory patients in the future.

An investigation into quality of life improvement in patients undergoing microvascular decompression for hemifacial spasm

OBJECTIVE Hemifacial spasm (HFS) is a movement disorder characterized by involuntary spasms of the facial muscles, and it can negatively impact quality of life (QOL). This retrospective study and systematic review with meta-analysis was conducted to investigate the QOL in patients with HFS following intervention with microvascular decompression (MVD) and botulinum toxin (BT). METHODS In the retrospective analysis, a QOL questionnaire was administered to all patients undergoing MVD performed by a single surgeon. The QOL questionnaire included unique questions developed based on the authors' experience with HFS patients in addition to the health-related QOL HFS-8 questionnaire. The authors also report on a systematic review of the English literature providing outcomes and complications in patients with HFS undergoing treatment with either MVD or BT. RESULTS Regarding the retrospective analysis, 242 of 331 patients completed the questionnaire. The mean score of the 10 QOL questions improved from 22.78 (SD 9.83) to 2.17 (SD 5.75) following MVD (p < 0.001). There was significant improvement across all subscales of the questionnaire between pre- and postoperative responses (p < 0.001). Regarding the systematic review, it is reported that approximately 90% of patients undergoing MVD for HFS experience a complete recovery from symptoms, whereas the mean peak improvement of symptoms following treatment with BT is 77%. Furthermore, patients undergoing MVD reported a greater improvement in the mean supplemental index of QOL as compared with patients receiving BT therapy. CONCLUSIONS Microvascular decompression offers a significant improvement in QOL in well-selected patients suffering from HFS, and may offer an increased benefit for QOL over BT injections.

Treatment of hemifacial spasm with botulinum toxin type a: effective, long lasting and well tolerated

ABSTRACT Hemifacial spasm (HFS) is a common movement disorder characterized by involuntary tonic or clonic contractions of the muscles innervated by the facial nerve. Objective To evaluate the long-term effect of botulinum toxin type A (BTX-A) in the treatment of HFS. Methods A retrospective analysis of patients treated at the Movement Disorders Outpatient Clinic in the Neurology Service, Hospital de Clínicas, Federal University of Paraná, Curitiba, from 2009 to 2013 was carried out. A total of 550 BTX-A injections were administered to 100 HFS patients. Results Mean duration of improvement following each injection session was 3.1 months, mean latency to detection of improvement was 7.1 days and mean success rate was 94.7%. Patients were evaluated at an interval of 5.8 months after each application. Adverse effects, which were mostly minor, were observed in 37% of the patients at least once during follow-up. The most frequent was ptosis (35.1%). Conclusion Treatment of HFS with BTX-A was effective, sustainable and safe and had minimal, well-tolerated side effects.