Assessment of Blepharospasm Surgery Using an Improved Disability Scale: Study of 138 Patients

Patient-reported outcomes following a break in ophthalmic botulinum toxin therapy during the COVID-19 pandemic

OBJECTIVE

To evaluate the effect of a break in botulinum toxin treatment, necessitated by the COVID-19 pandemic, on patients' quality of life.

METHODS

Prospective cohort study of all patients undergoing incobotulinumtoxinA treatment in our department-for benign essential blepharospasm (BEB), hemifacial spasm (HFS), aberrant facial regeneration (AFR), or crocodile tears-who were affected by the break in service (March 18, 2020-June 17, 2020). All patients who received treatment both before and after the break in service were included. Data gathered included subjective patient-reported measure of "time until treatment failure" and disease rating scale scores: Blepharospasm-Dystonia Functional Disability Assessment Scale (BDFDAS; for BEB, HFS, and AFR); Jankovic Rating Scale (JRS; for BEB and HFS); and TEARS Epiphora Grading Scale (for crocodile tears).

RESULTS

Across 72 patients, there was a mean treatment delay of 3.9 months (range, 0-9.8 months). After a period of effect, treatment failed in all patients, with a mean time until treatment failure of 3.9 months (range, 0.5-12.0 months). All patient-reported outcome measurements increased, with greatest effect seen in AFR (178% increase in BDFDAS) and BEB (41% increase in JRS). At least 2 patients sought and underwent retreatment elsewhere in the private sector because of their symptom severity.

CONCLUSIONS

Patients with AFR and BEB are likely to tolerate a break in service least, whereas patients with crocodile tears appear to be less affected. This real-world snapshot allows quantification of the harm caused by a break in botulinum toxin service or a treatment delay. This study provides valuable information should further breaks in service or treatment delay be considered in the future due to a further wave of COVID-19 or other reasons.

Blepharospasm Secondary to Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson Disease: Clinical Characteristics and Management Outcomes

BACKGROUND

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an effective treatment for patients with motor symptoms of Parkinson disease but can be complicated by disabling blepharospasm and apraxia of eyelid opening (ALO). Currently, there is no clear consensus on optimal management, and addressing these issues is further hindered by systemic morbidity and resistance to treatments. We aim to describe the different phenotypes of these eyelid movement disorders, to report our management approach and patient responses to treatment.

METHODS

A retrospective case series of all patients with blepharospasm/ALO secondary to STN-DBS that were treated at a tertiary center between 2011 and 2020. Data collected included date of Parkinson diagnosis, date of DBS surgery, date of development of blepharospasm/ALO symptoms, STN-DBS stimulation settings, and treatment given. Patients' symptoms before and after treatment were measured using the blepharospasm disability index and Jankovic Rating Scale.

RESULTS

Five patients were identified with eyelid movement disorders secondary to STN-DBS. All patients had moderate-to-severe symptoms at presentation. Four patients received periocular botulinum toxin injections. Three patients underwent surgery in the form of frontalis suspension or direct brow lift with or without upper lid blepharoplasty. All reported an improvement in symptoms following treatment.

CONCLUSIONS

A multimodality, patient-specific approach is required in the treatment of blepharospasm/ALO secondary to STN-DBS. Botulinum toxin injections can be effective, but patients may require surgery if toxin treatment alone becomes ineffective. Tailoring treatment to individual needs can result in a measurable improvement in symptoms.

Extended frontalis orbicularis oculi muscle flap shortening for treating refractory apraxia of eyelid opening associated with blepharospasm

BACKGROUND

Refractory apraxia of eyelid opening (AEO) is mostly unresponsive to botulinum toxin (BTx) and inevitably leads to functional blindness. To treat this challenging condition, an innovative surgical technique was proposed.

METHODS

The extended frontalis orbicularis oculi muscle (FOOM) flap shortening consisting of frontalis suspension, partial myectomy, and myotomy in situ of eyelid protractors was applied to treat refractory AEO associated with blepharospasm. The postoperative outcomes and patient satisfaction were evaluated.

RESULTS

Seven patients (mean ages 64.1 ± 3.9 years) of 14 eyelids in total had an average flap shortening distance of 24.4 ± 1.3 mm. During a mean follow-up of 31.6 ± 11.4 months, the average BTx dosage reduced from 58.6 ± 12. 1 units to 30.0 ± 8.2 units, with a mean injection interval decreasing from 2.3 ± 0.5 months to 4.1 ± 0.9 months (p < 0.05). Palpebral fissure height increased from 1.4 ± 0.5 mm to 7.9 ± 0.7 mm, and the disability scale decreased from 78.8% ± 7.2% to 12.6% ± 7.0% (p < 0.05). The postoperative BTx dosage and frequency were significantly reduced. All patients restored voluntary eyelid opening and reported high postoperative satisfaction (average Likert scale 4.6 ± 0.5).

CONCLUSION

Extended FOOM flap shortening is an effective treatment to solve refractory AEO associated with blepharospasm.

Clinical Features and Evolution of Blepharospasm: A Multicenter International Cohort and Systematic Literature Review

Objective:

Blepharospasm is a type of dystonia where the diagnosis is often delayed because its varied clinical manifestations are not well recognized. The purpose of this study was to provide a comprehensive picture of its clinical features including presenting features, motor features, and non-motor features.

Methods:

This was a two-part study. The first part involved a systematic literature review that summarized clinical features for 10,324 cases taken from 41 prior reports. The second part involved a summary of clinical features for 884 cases enrolled in a large multicenter cohort collected by the Dystonia Coalition investigators, along with an analysis of the factors that contribute to the spread of dystonia beyond the periocular region.

Results:

For cases in the literature and the Dystonia Coalition, blepharospasm emerged in the 50s and was more frequent in women. Many presented with non-specific motor symptoms such as increased blinking (51.9%) or non-motor sensory features such as eye soreness or pain (38.7%), photophobia (35.5%), or dry eyes (10.7%). Non-motor psychiatric features were also common including anxiety disorders (34–40%) and depression (21–24%). Among cases presenting with blepharospasm in the Dystonia Coalition cohort, 61% experienced spread of dystonia to other regions, most commonly the oromandibular region and neck. Features associated with spread included severity of blepharospasm, family history of dystonia, depression, and anxiety.

Conclusions:

This study provides a comprehensive summary of motor and non-motor features of blepharospasm, along with novel insights into factors that may be responsible for its poor diagnostic recognition and natural history.

Disabling muscle of Riolan: A novel concept of orbicularis oculi myectomy for refractory benign essential blepharospasm

PURPOSE

To examine the effectiveness of orbicularis oculi myectomy with disabling the muscle of Riolan in patients with benign essential blepharospasm refractory to botulinum toxin-A (BTX-A) injection.

METHODS

This retrospective, observational study included 25 patients. After removal of the redundant skin and underlying orbicularis oculi muscle (OOM) with or without extended OOM removal to the area of the superior orbital rim, the tarsal plate and the gray line were vertically severed at 2 points to disable the muscle of Riolan. The surgical effectiveness was evaluated using the visual analogue scale (VAS), functional disability score (FDS), and the presence or absence of necessity or enhanced effectiveness of BTX-A injection after surgery.

RESULTS

The symptoms improved in 23 patients (92.0%). The VAS and total FDS were significantly improved from 8.4 ± 1.7 to 4.0 ± 2.4 (reduction rate, 50.7 ± 35.6%) and from 74.6 ± 22.2 to 34.7 ± 25.3 (reduction rate, 53.4 ± 27.4%) after surgery, respectively (both, p < 0.001). Among the 23 patients whose symptoms improved after surgery, BTX-A injection was not required in 11 of them (47.8%). Among the remaining 12 patients (52.2%), the effectiveness of BTX-A was post-operatively enhanced in eight patients (34.8%). There were no serious complications, and none of the patients experienced madarosis.

CONCLUSION

Disabling the muscle of Riolan is a valuable option of OOM myectomy in patients with refractory benign essential blepharospasm, without the development of serious complications, including madarosis.

Polytetrafluoroethylene frontalis suspension in blepharospasm with eyelid apraxia: an effective and well-tolerated adjunct to botulinum toxin therapy

Purpose: To report the efficacy of polytetrafluoroethylene (PTFE) frontalis suspension for blepharospasm with eyelid apraxia and postoperative botulinum toxin requirements. Methods: Retrospective chart review of patients with blepharospasm and eyelid apraxia who underwent frontalis suspension. The primary outcome was a surgical success, defined by surgeon- and patient-reported success in postoperative eyelid opening. Comparative statistical analyses of botulinum toxin dosage and treatment intervals were performed amongst patients before and after frontalis suspension ptosis repair. Results: Five patients (10 eyelids) met the study criteria, of which 40% were female. Mean age was 63.2 years. All patients had successful surgical outcomes based on physician-reported and patient reported satisfaction with the postoperative eyelid opening. Average follow-up was 14 months. Preoperative botulinum toxin treatments averaged 80.4 units (range 32-110, SD 33.2) to the periocular region over an average of 9.6-week intervals. Postoperative botulinum toxin treatments averaged 61.4 units (range 24-110, SD 34.7) to the periocular region over an overage of 9.8-week intervals. No patients experienced postoperative exposure keratopathy, extrusion of the sling, or postoperative infection. Conclusions: Frontalis suspension using PTFE suture in the setting of blepharospasm with eyelid apraxia was found to be a safe and effective procedure. Frontalis suspension in this population is not a substitute for botulinum toxin treatment but may allow for reduced treatment dosage. Frontalis suspension appears to increase patient functionality with improved eyelid opening in patients with blepharospasm with eyelid apraxia.

Medical and Surgical Treatments for Dystonia

The dystonias are a large and heterogenous group of disorders characterized by excessive muscle contractions leading to abnormal postures and/or repetitive movements. Their clinical manifestations vary widely, and there are many potential causes. Despite the heterogeneity, helpful treatments are available for the vast majority of patients. Symptom-based therapies include oral medications, botulinum toxins, and surgical interventions. For some subtypes of dystonia, specific mechanism-based treatments are available. Advances in understanding the biological basis for many types of dystonia have led to numerous recent clinical trials, so additional treatments are likely to become available in the very near future.

The Dystonias

PURPOSE OF REVIEW

This article provides a summary of the state of the art in the diagnosis, classification, etiologies, and treatment of dystonia.

RECENT FINDINGS

Although many different clinical manifestations of dystonia have been recognized for decades, it is only in the past 5 years that a broadly accepted approach has emerged for classifying them into specific subgroups. The new classification system aids clinical recognition and diagnosis by focusing on key clinical features that help distinguish the many subtypes. In the past few years, major advances have been made in the discovery of new genes as well as advances in our understanding of the biological processes involved. These advances have led to major changes in strategies for diagnosis of the inherited dystonias. An emerging trend is to move away from heavy reliance on the phenotype to target diagnostic testing toward a broader approach that involves large gene panels or whole exome sequencing.

SUMMARY

The dystonias are a large family of phenotypically and etiologically diverse disorders. The diagnosis of these disorders depends on clinical recognition of characteristic clinical features. Symptomatic treatments are useful for all forms of dystonia and include oral medications, botulinum toxins, and surgical procedures. Determination of etiology is becoming increasingly important because the number of disorders is growing and more specific and sometimes disease-modifying therapies now exist.

Treatment Effects of Botulinum Toxin Injection and Acupuncture on Blepharospasm Assessed by the Change in Lower Eyelid Tension

Objective: To investigate the treatment effects of botulinum toxin-A (BTA) injection and acupuncture on blepharospasm (BP) evaluated by the change in lower eyelid tension (LET). Methods: A series of 30 patients (male: 8, female: 22) aged between 37 and 83 years (63.80 ± 10.96 yrs) who met the eligibility criteria of BP were recruited in this study, who were randomly assigned to BTA injection group (BTA group, n = 15) and acupuncture treatment group (Acupuncture group, n = 15). BTA injections were administered to the patients in BTA group while patients in acupuncture group received the acupuncture treatment. The LET was measured by a tensiometer in both groups at baseline and at post-treatment. Results: A significant decrease in LETs over 8 weeks was found in acupuncture group (812.76 ± 193.95 Pa at baseline, 549.69 ± 150.04 Pa at 4 weeks, and 510.96 ± 150.66 Pa at 8weeks, respectively; F = 31.127, p << 0.001). There was a significant decrease in LET from 858.61 ± 190.54 Pa at baseline to 414.45 ± 63.38 Pa at 2 weeks after treatment (Z = -4.542, p << 0.01) in BTA group. At the endpoint of the study, a significant difference in LET was found between the acupuncture group (301.80 ± 181.77 Pa) and the BTA group (444.16 ± 193.44 Pa) (t = -2.077, p = 0.047). Conclusions: BP patients have an increased LET. Both BTA and acupuncture are effective in decreasing the LET. Close monitoring of LET holds promise in planning the treatment strategy for Blepharospasm.

Surgical approach to limiting skin contracture following protractor myectomy for essential blepharospasm

Purpose

To report our experience with protractor myectomy in patients with benign essential blepharospasm who did not respond to serial botulinum toxin injection, and to describe intra- and postoperative techniques that limited skin contracture while also providing excellent functional and cosmetic results.

Methods

The medical records of patients with isolated, benign, essential blepharospasm who underwent protractor myectomy from 2005 to 2008 by a single surgeon were reviewed retrospectively. The technique entailed operating on a single eyelid during each procedure, using a complete en bloc resection of all orbicularis tissue, leaving all eyelid skin intact at the time of surgery, and placing the lid under stretch with Frost suture and applying a pressure dressing for 5-7 days.

Results

Data from 28 eyelids in 7 patients were included. Average follow-up was 21.5 months (range, 4-76 months). Of the 28 eyelids, 20 (71.4%) showed postoperative resolution of spasm, with no further need for botulinum toxin injections. In the 8 eyelids requiring further injections, the average time to injection after surgery was 194 days (range, 78-323 days), and the average number of injections was 12 (range, 2-23 injections). All but one eyelid had excellent cosmetic results, without signs of contracture; one eyelid developed postoperative skin contracture following premature removal of the Frost suture and pressure dressing because of concerns over increased intraocular pressure.

Conclusions

In our patient cohort, this modified technique resulted in excellent cosmetic and functional results and limited postoperative skin contracture.

Surgical Correction of the Intractable Blepharoptosis in Patients With Ocular Myasthenia Gravis

PURPOSE

Treatment of blepharoptosis caused by ocular myasthenia gravis (OMG) is challenging in patients with serious side effects or failed response to medical therapy. Only a few surgical reports have been published for refractory myathenic blepharoptosis. This study is aimed at the evaluation of the surgical outcome of blepharoptosis correction in intractable OMG patients.

METHODS

Twelve OMG patients who accepted frontalis sling with frontalis orbicularis oculi muscle (FOOM) flap for blepharoptosis correction were reviewed. Patients' demographies, perioperative changes of the interpalpebral fissure height (IPFH), margin reflex distance 1 (MRD1), levator function (LF), and quality of life (QOL) score were evaluated.

RESULTS

The duration of OMG ranged from 3 to 31 years. LF was normal in 6 patients, good in 5, and poor in 1. There is no significant change of LF before and after surgery. MRD1 improved significantly from -1.8 mm (range, 0 to -5 mm) preoperatively to 2.9 mm (range, 2-4 mm) postoperatively. IPFH improved significantly from 3.8 mm (range, 2-6 mm) preoperatively to 7.8 mm (range, 6-9 mm) postoperatively. Upper eyelid margin was above the pupil in all patients. QOL score improved significantly from 18.2 (range, 14-23) preoperatively to 5.8 (range, 0-10) postoperatively.

CONCLUSIONS

Our report reveals that surgical correction of the blepharoptosis is effective for patients with intractable OMG and that frontalis suspension with FOOM flap is a valuable option because of its ready availability and pliability. All patients are satisfied with the results, especially the improvement of QOL.

Diagnosis and treatment of dystonia

The dystonias are a group of disorders characterized by excessive involuntary muscle contractions leading to abnormal postures and/or repetitive movements. A careful assessment of the clinical manifestations is helpful for identifying syndromic patterns that focus diagnostic testing on potential causes. If a cause is identified, specific etiology-based treatments may be available. In most cases, a specific cause cannot be identified, and treatments are based on symptoms. Treatment options include counseling, education, oral medications, botulinum toxin injections, and several surgical procedures. A substantial reduction in symptoms and improved quality of life is achieved in most patients by combining these options.

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.

Frontalis suspension surgery to treat patients with essential blepharospasm and apraxia of eyelid opening-technique and results

INTRODUCTION

We describe the results of 15 patients suffering from essential blepharospasm with apraxia of eyelid opening who underwent frontalis suspension surgery.

MATERIAL AND METHODS

Patients with apraxia of eyelid opening and unresponsive to botulinum toxin injections were studied. Bilateral frontalis suspension surgery was performed (sling operation) using polytetrafluoroethylene (Gore-Tex®) sutures. The patients reported the degree of improvement using a subjective rating scale to evaluate the benefit of the operation at two times after surgery (0-10 days and 180-360 days).

RESULTS

The patients reported a high degree of subjective improvement. In the early postoperative period (0-10 days) the mean degree of subjective improvement was 74.6% (standard deviation (SD) 26.4%). At 180-360 days after surgery the mean improvement was 70.0% (SD 26.7%). Small hematomas of the upper lid occurred postoperatively in all patients. Other complications were suture extrusions (9.1%), suture granulomas (6.1%), lacrimation (5.0%) and local infections (7.5%). Postoperatively, all patients needed additional botulinum toxin injections for optimal outcome.

CONCLUSION

Frontalis suspension surgery is a minimally invasive and effective treatment option for apraxia of eyelid opening in patients with essential blepharospasm unresponsive to botulinum toxin injections alone.

Skin contracture following upper eyelid orbiculectomy: is primary skin excision advisable?

AIM

To report the incidence and consequences of skin contracture following upper eyelid orbiculectomy.

METHODS

A retrospective case note review identified 8 consecutive patients undergoing skin sparing upper eyelid limited orbiculectomy for essential blepharospasm associated with apraxia of eyelid opening. Clinical data collected from this review included age, gender, type of surgery performed, surgical complications, the need for additional surgeries, botulinum toxin treatment after surgery, dry eyes and blepharospasm functional disability assessment score. Pre and post operative photographs (at 1 year follow up) were used to assess the change in upper eyelid skin.

RESULTS

The mean preoperative functional disability score was 72 ± 18 and improved to 25 ± 18 postoperatively at last follow-up. One patient needed botulinum toxin injections postoperatively. Intraoperative complications included bleeding in one case and haematoma in another case. Although we did not excise excess skin in any of our cases, we noted a reduction in upper eyelid skin excess in all cases, postoperatively. Restrictive lagophthalmos was noted in 3 cases (who had orbiculectomy alone) which required skin grafting and/or levator recession.

CONCLUSION

Upper eyelid limited orbiculectomy with meticulous attention to pre-tarsal and pre-septal orbicularis only is effective in improving apraxia of eyelid opening and blepharospasm. Although we did not excise excess skin in any of our cases, we noted skin contracture postoperatively in three cases severe enough to require skin grafting or scar release. In our experience, skin contracture and orbital septal scarring appears to be relatively common following upper eyelid orbiculectomy, particularly if pre-tarsal and septal orbicularis is meticulously excised. In such a scenario we suggest avoiding concurrent excision of any dermatochalasis.

Current and future medical treatment in primary dystonia

Dystonia is a hyperkinetic movement disorder, characterized by involuntary and sustained contractions of opposing muscles causing twisting movements and abnormal postures. It is often a disabling disorder that has a significant impact on physical and psychosocial wellbeing. The medical therapeutic armamentarium used in practice is quite extensive, but for many of these interventions formal proof of efficacy is lacking. Exceptions are the use of botulinum toxin in patients with cervical dystonia, some forms of cranial dystonia (in particular, blepharospasm) and writer's cramp; deep brain stimulation of the pallidum in generalized and segmental dystonia; and high-dose trihexyphenidyl in young patients with segmental and generalized dystonia. In order to move this field forward, we not only need better trials that examine the effect of current treatment interventions, but also a further understanding of the pathophysiology of dystonia as a first step to design and test new therapies that are targeted at the underlying biologic and neurophysiologic mechanisms.

Treatments for neuro-ophthalmologic conditions

Neuro-ophthalmology covers disorders that fall between the cracks of Neurology and Ophthalmology. Neurologists see patients with neuro-ophthalmic disorders. Recognition of the diagnosis is difficult enough, but treatment can be challenging. This article reviews several common neuro-ophthalmic disorders, outlining their features and treatments, from retinal vascular disorders to eye movements and blepharospasm.

Review and update of involuntary facial movement disorders presenting in the ophthalmological setting

We review the existing literature on the involuntary facial movement disorders-benign essential blepharospasm, apraxia of eyelid opening, hemifacial spasm, and aberrant facial nerve regeneration. The etiology of idiopathic blepharospasm, a disorder of the central nervous system, and hemifacial spasm, a condition involving the facial nerve of the peripheral nervous system, is markedly different. We discuss established methods of managing patients and highlight new approaches.

Videonystagmography to assess eyelid dynamic disorders

OBJECTIVES

Apply a videonystagmography (VNG) device to study indirectly blinking in patients with essential blepharospasm.

PATIENTS AND METHODS

A VNG device was used to study the pupillary occlusion. It was recorded and analyzed as indirect parameters of blinking in 23 essential blepharospasm on day 0, month 1, and month 3 following botulinum toxin injection using VNG.

RESULTS

Botulinum toxin significantly reduced pupillary occlusions (PO) frequency (9.6 PO/min on D0 and 4.7 PO/min on M1 (p = 0.004), and average PO time (0.95 sec on D0 and 0.58 sec on M1 (p = 0.03) for PO higher than 0.3 sec. On the other hand, it does not have any action on frequency (32.4 PO/min on D0 and 31.3 PO/min on M1 (p = 0.7) and average PO time (0.16 sec on D0 and 0.15 sec on M1 (p = 0.4) of PO lower than 0.3 sec.

CONCLUSION

Video acquisition computer-assisted makes it possible to measure blinking parameters indirectly in real time and to assess essential blepharospasm objectively. The protocol analysis of PO is attractive for indirect analysis of blinking.

Upper eyelid myectomy in blepharospasm with associated apraxia of lid opening

PURPOSE

To assess the impact of upper eyelid myectomy surgery on blepharospasm with associated apraxia of lid opening (ALO), dry eye, photophobia, and daily functioning in patients who are refractory to botulinum toxin treatment.

DESIGN

Noncomparative, consecutive, interventional case series.

METHODS

A retrospective chart review was performed to identify 100 consecutive patients beginning on January 1, 2000, who underwent upper eyelid myectomy surgery for blepharospasm and fulfilled the inclusion criteria. A survey was sent to all patients. Data were entered in an anonymous manner into a spreadsheet and analysis was performed using the Student t test with significance set at P<.05.

RESULTS

Forty-five (88%) patients experienced ALO before surgery, among which 15 (33%) patients stated they were completely cured and 20 (44%) others had more than 50% improvement in ALO with surgery. In 20 of 30 patients who continued botulinum toxin treatment after surgery, the effect lasted longer. Twelve (29%) of 42 patients who experienced dry eyes before surgery improved. Eighteen (41%) of the 44 patients who experienced light sensitivity before surgery improved. Thirty-seven (82%) patients noted their cosmetic appearance to be better after surgery. The cumulative preoperative disability score was 14.11+/-5.78 (59%), whereas the cumulative postoperative disability score was 5.20+/-8.25 (22%; P<.01).

CONCLUSIONS

Upper eyelid myectomy surgery appears to be effective in treating blepharospasm with associated ALO in most patients who are refractory to botulinum toxin injections and can provide improvement in the quality of life.

What is new in the era of focal dystonia treatment? Botulinum injections and more

PURPOSE OF REVIEW

The treatment options for the management of dystonias continue to evolve and improve. Clinical outcomes, however, are not predictably consistent using a single treatment regimen in all patients.

RECENT FINDINGS

Botulinum toxin is still considered the best treatment option for the treatment of focal dystonias: blepharospasm, hemifacial spasm, and apraxia of eyelid opening. New findings indicate that physicians may be a little more aggressive with the dosage when the disease progresses. A new formulation of botulinum toxin has been produced that includes no proteins and may address the immunoresistance that can occur with prolonged use. Additional systemic medications may be helpful as adjuncts only in selected cases. Improved surgical techniques are now more successful and cause fewer complications. Therefore, many refractory cases are now offered a surgical approach alone or in combination with botulinum toxin.

SUMMARY

There have been recent therapeutic developments in the treatment of ocular dystonias.

Long-term follow-up of patients with frontalis sling operation in the treatment of essential blepharospasm unresponsive to botulinum toxin therapy

OBJECTIVE

Botulinum toxin is the treatment of choice in patients with essential blepharospasm, but about 4% of patients show no sufficient effect. Many of these patients try to open their eyes by innervating their frontalis muscle. This led to the idea of performing frontalis suspension, normally used for certain types of ptosis. We set out to evaluate the long-term results, complication rates and patient acceptance of this intervention.

METHODS

Frontalis sling operation was carried out on 252 eyes of 132 blepharospasm patients between 1992 and 2004. In all patients botulinum toxin treatment was administered before surgery with no or only brief and incomplete effect even with increasing toxin doses. In 120 patients surgery was performed under local anaesthesia, while 12 patients were operated upon under general anaesthesia (mostly bilateral). Silk sutures were employed in the first 14 eyes, and in all others we used Gore-Tex suture material.

RESULTS

The duration of follow-up was 3-154 months; 60 patients were followed up for at least 5 years. Seventy-three per cent of patients reported an improvement after surgery. Long-term subjective improvement showed a median of 50% on a scale ranging from 0%=no improvement to 100%=no complaints. No serious corneal complications occurred, although slight overcorrection is desirable in the first days after surgery for a satisfactory long-term result. Seven per cent of operations had to be revised due to suture granulomas or extruded suture material. The effect of surgery generally remained stable over the years, with most patients needing additional treatment with botulinum toxin. In cases of decreasing effect (5% of eyes), the sutures were tightened under local anaesthesia.

CONCLUSION

Frontalis suspension can be considered as a minimally invasive but very effective and even reversible procedure in "poor responders" to botulinum toxin, with good long-term effect and good acceptance by the patients. Additional treatment with botulinum toxin is required in most patients in order to increase the desirable imbalance between the frontalis and the orbicularis muscle.