Relationship among eye condition sensitivities, photosensitivity and epileptic syndromes:

Electrographic Features of Epilepsy With Eyelid Myoclonia With Photoparoxysmal Responses

PURPOSE

Epilepsy with eyelid myoclonia (EMA) is characterized by eyelid myoclonia, eyelid closure sensitivity, and photosensitivity. EEG may manifest with frontal-predominant (FPEDs) or occipital-predominant epileptiform discharges (OPEDs). Data on clinical and electrographic features of these two subtypes are lacking. The purpose of our research was to look at baseline electroclinical features of EMA subtypes and to study electrographic findings of patients with EMA during intermittent photic stimulation (IPS).

METHODS

We retrospectively identified all patients who had photoparoxysmal responses on EEGs performed at Cleveland clinic between January 01, 2012, and December 31, 2019. Patients who met diagnostic criteria for EMA were studied further.

RESULTS

Of the 249 patients with photoparoxysmal responses, 70 (28.1%) had EMA (62 [88.6%] female; the mean age of epilepsy onset: 7.0 ± 7.9 years). Patients with EMA had either FPEDs or OPEDs. Eleven patients with EMA (15.7%) had seizures (4 absence, 5 myoclonic and 2 bilateral tonic-clonic) during IPS. Patients with OPEDs were more likely to have drug-resistant epilepsy; occipital focal IEDs and other focal IEDs (other than frontal/occipital) on baseline EEG; and generalized IEDs with occipital predominance, generalized IEDs with no predominance, or focal IEDs during IPS. Predictors of seizure occurrence during photic stimulation included the presence of focal occipital IEDs on baseline EEG, generalized IEDs with frontal predominance during IPS, and photoparoxysmal response outlasting the stimulus.

CONCLUSIONS

Our study provides evidence that EMA has two distinct subtypes, which differ in clinical characteristics, baseline EEG, and EEG during photic stimulation. We highlight diagnostic and prognostic implications of these findings. Our study also details EEG characteristics of patients with EMA during IPS.

Jeavons syndrome featured with visual sensitivity existing as occipital cortex originating focal-to-generalized continuum epilepsy

OBJECTIVE

To study the relationship between eye closure sensitivity (ECLS), photosensitivity, and the mechanism of Jeavons syndrome (JS).

METHODS

The interictal and the ictal epileptiform discharges (EDs) of 80 patients with electroencephalograms were classified (I: focal posterior EDs; II: the posterior spread into the frontal EDs; and III: generalized EDs) and analyzed under different provoked conditions.

RESULTS

During the interictal and the ictal period, the positive rates of ECLS were higher than those of photosensitivity (100% vs 57.5%, P = 0.001; 97.5% vs 27.4%, P = 0.001). After a one-year interval, eyelid-myoclonia with ECLS remitted in 16 out of 21 patients (P = 0.002), and eyelid-myoclonia with photo-convulsion response (PCR) disappeared in all the previous six patients (P = 0.021). For the interictal EDs with ECLS, grade I accounted for 11.2%; grade I, II, and III 51.3%; and grade III 32.5%. Interictal EDs classification of photosensitivity showed a similar trend as that of ECLS. For the ictal EDs, grade I accounted for 10.2% of patients with ECLS and 6.7% of patients with PCR; grade I, II, and III, 33.3% of patients with ECLS and 46.6% of patients with PCR; and grade III, 53.9% of patients with ECLS and 40% of patients with PCR.

CONCLUSION

ECLS was more common than photosensitivity in JS. Photosensitivity was more likely to disappear than ECLS. Both eye closure and intermittent-photic-stimulation could induce three grades of EDs, confirming that visual stimuli could trigger occipital cortex originating epileptic neural network to varying degrees, which further recognizes JS as another continuum epilepsy.

Investigation of Patients With Eye Closure Sensitive Epilepsy With Magnetic Resonance Spectroscopy

Introduction and aim: A proportion of patients diagnosed with genetic generalized epilepsy (GGE) experience eye-closure sensitivity (ECS), the underlying pathogenesis of which is unknown. In this study, we compare magnetic resonance spectroscopy (MRS) findings of healthy volunteers with patients diagnosed with GGE, with and without ECS, to detect possible explanatory differences between groups. Materials and methods: A total of 33 patients diagnosed with GGE: 17 with ECS and 16 without, and 12 healthy volunteers are included. MRS measurements of N-acetyl-aspartate (NAA), choline (Cho), and creatine (Cr) were made of bilateral occipital lobes and thalamus, and values of patients with GGE were compared with those of normal controls, and within subgroups with different clinical variables, using appropriate statistical tests. Results: Left occipital NAA and NAA/Cr levels were found to be significantly higher in the ECS group than in the control group. In the ECS epilepsy group, a significant moderate positive correlation was noted between left thalamic Cr and duration of drug therapy (r = .539, P = .047) and left thalamic Cr and age at epilepsy onset (r = .564, P = .036). Additionally, left thalamic NAA and NAA/Cr levels were observed to be lower in GGE patients compared to healthy subjects, although not to a statistically significant degree. Conclusion:The differences in MRS-measurable metabolites in the left occipital lobe in those with ECS epilepsy suggest an association between the ECS mechanism and the left occipital lobe. Our results also support the multifocal thalamocortical pathway disorder in the pathophysiology of GGE based on the observation of cellular dysfunction in the thalamus.

Eye closure sensitivity and genetic generalized epilepsies: A prospective study of 123 cases

PURPOSE

To investigate the possible relationship between eye closure sensitivity (ECS) and genetic generalized epilepsy (GGE) in terms of epilepsy syndromes, photosensitivity (PS), and prognosis.

METHOD

One hundred and twenty-three patients diagnosed with GGE were classified according to epilepsy syndromes. Among them, ECS and PS were detected in repeated video-EEGs. In patients with ECS, the impact of sleep deprived EEG on awakening on ECS was evaluated. To explore the ECS as a possible accurate predictor designating the prognosis in GGEs, we defined the ECS rate in poor prognosis group (n = 21) and in patients without antiseizure drug (ASD) treatment and seizure-free for at least for 2-5 years (n = 20).

RESULTS

ECS was found in almost all types of GGE but at different rates. ECS was detected in all groups with highest rate in eyelid myoclonia with or without absences (EMA). Sleep deprived EEG on awakening was performed in 44 of 59 patients with ECS and enhanced ECS prominently. In all groups except EMA, PS rate was lower compared with ECS. Both ECS and PS were observed in 15 patients with poor prognosis (71 %) and one patient with good prognosis (5%).

CONCLUSIONS

ECS can occur in all types of the GGEs. We claim that ECS can be asserted as a syndrome-specific feature for EMA among GGEs. Sleep deprived EEG on awakening can enhance ECS prominently in all types of GGE. ECS and PS might overlap but their impact on prognosis is different. In the poor prognosis group, the number of patients having ECS together with PS was high compared to the group without ASD and excellent prognosis. Therefore, we suggest that this combination predicts worse outcome in GGEs.

The clinical significance and electrophysiologic findings of fixation-off and closure of the eyes sensitivity: Data from a prospective unselected population

PURPOSE

Electroencephalography (EEG) findings related to the eye-closing motion can be defined in two ways: 'sensitivity to eyes closed' (SEC) and 'eye closure sensitivity (ECS).' Fixation-off sensitivity (FOS) is a different phenomenon induced by the elimination of central vision/fixation. The purpose of our study was to determine the frequencies of SEC, ESC, and FOS, and to analyze the relationship between eyes closure and the fixation-off phenomenon and clinical importance in an unselected population.

METHODS

We prospectively evaluated 200 routine interictal EEGs by adding a standardized FOS examination protocol between June and September 2015. Goggles covered with semitransparent tape were used to evaluate FOS. We determined SEC when the epileptiform discharges appeared during eye closure and continued during the eye closed state, whereas ECS was defined as transient epileptic abnormalities following the closure of the eyes lasting for 1-4 sec. The patients were evaluated in terms of demographic characteristics, clinical features, and the relationship between SEC, ECS, and FOS.

RESULTS

We detected SEC in 9 (4.4 %) and ECS in 11 (5.4 %) patients. FOS was detected in four (44.4 %) of the patients who showed SEC, all of whom had occipital epileptiform discharges. A statistically significant correlation was found between FOS and treatment resistance in the SEC group (p < 0.001). In logistic regression analysis, occipital lobe epilepsy (p < 0.001) and age under 20 years (p = 0.004) were found as risk factors for SEC. Another interesting finding was the suppression of epileptic discharges with fixation-off in three of 11 patients with ECS.

CONCLUSIONS

According to the results of our study, FOS is related to treatment resistance. Therefore, FOS should be evaluated in patients with SEC.

Genetic (idiopathic) epilepsy with photosensitive seizures includes features of both focal and generalized seizures

Clinically, some patients having genetic (idiopathic) epilepsy with photosensitive seizures were difficult to be diagnosed. We aimed to discuss whether the genetic (idiopathic) epilepsy with photosensitive seizures is a focal entity, a generalized entity or a continuum. Twenty-two patients with idiopathic epilepsies and photoconvulsive response (PCR) were retrospectively recruited. In the medical records, the seizure types included “generalized tonic-clonic seizures (GTCS)” in 15, “partial secondarily GTCS (PGTCS)” in 3, partial seizures (PS) in 3, myoclonic seizures in 2, eyelid myoclonus in one, and only febrile seizures in one. Seizure types of PCR included GTCS (1/22), PGTCS (6/22), PS (9/22), electrical seizures (ES) (3/22) and GTCS/PGTCS (3/22). Combined the medical history with PCR results, they were diagnosed as: idiopathic (photosensitive) occipital lobe epilepsy (I(P)OE) in 12, genetic (idiopathic) generalized epilepsy (GGE) in one, GGE/I(P)OE in 5, pure photosensitive seizure in one, and epilepsy with undetermined generalized or focal seizure in 3. So, the dichotomy between generalized and focal seizures might have been out of date regarding to pathophysiological advances in epileptology. To some extent, it would be better to recognize the idiopathic epilepsy with photosensitive seizures as a continuum between focal and generalized seizures.

Eyelid myoclonia seizures in adults: An alternate look at the syndrome paradox

OBJECTIVES

Eyelid myoclonia (EM), without or with absences (EMA), is induced by eye closure (ECL)-associated generalized paroxysms of polyspikes and waves. Although considered as an epileptic syndrome, it has been listed as a type of seizure in the recent epilepsy classifications, perhaps because of its clinical heterogeneity. In this study, we aimed to specifically study the clinical and electroencephalogram (EEG) features and the prognosis of long-term followed-up adult patients with EMs and to determine common points between EMAs, idiopathic generalized epilepsies (IGEs), and symptomatic epilepsies.

METHODS

Between 1996 and November 2011, 61 adult patients with EMs with or without absences and bilateral EEG paroxysms were retrospectively enrolled in the study and followed up for 1-34 years (mean: 5.8 years).

RESULTS

According to patient history, seizure semiology, and EEG findings, we classified the patients having EM seizures into three main groups. In group 1 (n=31), all patients had prominent EMs with or without absences associated with upward rolling of eyeballs. The second group included 20 patients with EM seizures associated with generalized tonic-clonic seizures (GTCSs) and/or massive myoclonias. The third group of 7 patients had varying diagnosis of symptomatic epilepsies. In the first group with pure EMA, the diagnosis was more delayed than in the other groups (p=0.01). In the group with pure EMA, EMs continued in adulthood (p=0.00), and only 24% of patients were seizure-free, which was considered poor prognosis. On EEG, occipital (n=3) and frontal (n=4) focal discharges were found in the group with pure EMA. Interestingly, 2 patients with symptomatic epilepsy with frontal lesions also had EM seizures.

CONCLUSION

The patients with pure EMA have many similarities to patients with IGEs. We also demonstrated that EMs could be seen as a seizure type in symptomatic epilepsies. Eyelid myoclonia with absences meets the criteria for an epileptic syndrome with the early onset and long duration of seizures, special seizure type, specific EEG findings, possibility of cognitive impairment, precipitating modalities, photosensitivity, and presence of family history, suggesting a strong genetic background.

Benign myoclonic epilepsy of infancy evolving to Jeavons syndrome

Benign myoclonic epilepsy of infancy is a rare idiopathic generalized epileptic syndrome occurring below the age of 3 years. Although benign outcome is presumed, some recent studies suggest less favorable outcome. A 14-year-old boy had a history of repeated episodes of myoclonic jerks of the shoulders and upper limbs in infancy (age 5 months). An ictal electroencephalogram indicated generalized spike-wave discharges associated with the myoclonic seizures, and the diagnosis of benign myoclonic epilepsy of infancy was made. Valproate treatment resulted in control of the myoclonic seizures, and the drug was withdrawn when the patient was 5 years of age. At the age of 10, he presented with episodes of eyelid jerks associated with brief lapses in concentration triggered by sunlight. Electroencephalography revealed photosensitivity and a pattern of eye-closure sensitivity. These features were compatible with the diagnosis of eyelid myoclonia with absences, or Jeavons syndrome. Lamotrigine eliminated the seizures. The evolution of benign myoclonic epilepsy of infancy to eyelid myoclonia with absences has been reported in one other case. A possible continuum of myoclonic epileptic syndromes, mediated by a common genetic abnormality, suggests the need for longer monitoring of patients with benign myoclonic epilepsy of infancy.