Are Cognitive Symptoms Part of the Phenotypic Spectrum of Idiopathic Adult-Onset Dystonia? Summary of Evidence from Controlled Studies

BACKGROUND

Cognitive dysfunction has been reported in idiopathic adult-onset dystonia (IAOD), but whether this is a primary or secondary component of the disorder remains uncertain.

OBJECTIVE

Here, we aimed to analyze the key domains of abnormal cognitive performance in IAOD and whether this is associated with motor or mood changes.

METHODS

Article selection for our critical review was guided by PRISMA guidelines (mesh terms "dystonia" and "cognitive," publication period: 2000-2022). Only peer-reviewed, English-language original case-control studies involving patients with IAOD who were not exposed to dopamine- or acetylcholine-modulating agents and validated cognitive assessments were included.

RESULTS

Abstract screening ultimately yielded 22 articles for full-text review and data extraction. A greater proportion of studies (17 of 22, 82%) reported abnormal cognitive performance in IAOD. Most of these studies focused on blepharospasm (BSP) and cervical dystonia (10 and 14, respectively). Most studies reporting cognitive impairment (11 of 17) identified multidomain impairment in cognition. Executive functions were the domain most frequently explored (14 of 22 studies), 79% of which detected worse performance in people with dystonia. Results related to other domains were inconclusive. Cognitive abnormalities were independent of motor symptoms in most studies (7 of 12) that explored this relationship and independent of mood status in all 8 that investigated this.

CONCLUSIONS

Within IAOD, cognitive dysfunction (in particular, executive dysfunction) has been documented mainly in BSP and cervical dystonia. More comprehensive testing is warranted to assess abnormalities in other domains and in other forms of IAOD, as well as to evaluate longitudinal progression of cognitive disturbances in this condition.

Sjogren's syndrome meets Meige's syndrome

This report details a rare case where a patient simultaneously suffered from Sjogren's syndrome (SS) and Meige's syndrome (MS). SS, an autoimmune disorder, and MS, a rare neurological condition characterized by involuntary eyelid closure, presented in a 73-year-old male. The patient had been experiencing dry eye symptoms for the past 5 years, with the onset of eyelid spasms and tetanic eye closure occurring 3 years ago. Traditional treatments, including subthalamic nucleus deep brain stimulation, provided only temporary relief. Diagnostic evaluations, including blood tests and imaging, confirmed SS and MS coexistence. Treatment involved a combination of steroids, immunosuppressants, and immunoglobulin, leading to significant symptom relief. This case suggests a potential association between SS and the development of MS, highlighting the importance of immunomodulatory therapy in managing neurological symptoms. Further research is needed to explore the relationship between these two conditions and to develop more effective treatment strategies.

Relations between nonmotor manifestations and motor disorders in patients with benign essential blepharospasm

PURPOSE

To evaluate the relations between nonmotor manifestations (dry eye, mood disorders, and sleep disturbance) and motor disorders in patients with benign essential blepharospasm (BEB), and to determine whether relieving motor disorders by botulinum neurotoxin can improve the nonmotor manifestations.

METHODS

In this prospective case series study, 123 BEB patients were enrolled for evaluations. Among them, 28 patients underwent botulinum neurotoxin therapy and attended another two postoperative visits at 1 month and 3 months. Motor severity was measured with Jankovic Rating Scale (JRS) and Blepharospasm Disability Index (BSDI). We assessed dry eye using OSDI questionnaire, Schirmer test, tear break-up time (TBUT), tear meniscus height, lipid layer thickness (LLT) and corneal fluorescence staining. Zung's Self-rating Anxiety and Depression Scale (SAS, SDS) and Pittsburgh Sleep Quality Index (PSQI) were for mood status and sleep quality evaluations.

RESULTS

Patients with dry eye or mood disorders had higher JRS scores (5.78 ± 1.13, 5.97 ± 1.30) than those without (5.12 ± 1.40, 5.50 ± 1.16; P = 0.039, 0.019, respectively). BSDI values of patients with sleep disturbance (14.61 ± 4.71) was higher than those without (11.89 ± 5.44, P = 0.006). Correlations were found between JRS, BSDI and SAS, SDS, PSQI, OSDI, TBUT. Botulinum neurotoxin effectively relieved JRS, BSDI and improved PSQI, OSDI, TBUT, LLT (8.11 ± 5.81, 21.77 ± 15.76, 5.04 ± 2.15 s, 79.61 ± 24.11 nm) at the 1-month visit compared to baseline (9.75 ± 5.60, 33.58 ± 13.27, 4.14 ± 2.21 s, 62.33 ± 22.01 nm; P = 0.006, < 0.001, = 0.027, < 0.001, respectively).

CONCLUSIONS

The BEB patients with dry eye, mood disorders, or sleep disturbance had more severe motor disorders. Motor severity was associated with the severity of the nonmotor manifestations. Relieving motor disorders by botulinum neurotoxin was effective in improving dry eye and sleep disturbance.

Evaluation of non-motor symptoms in cervical dystonia, hemifacial spasm, and blepharospasm patients and their correlation with motor symptoms

BACKGROUND

Awareness of non-motor symptoms has been increasing in recent years, but there are still few studies on this topic.

OBJECTIVE

Our aim was to evaluate various non-motor symptoms, especially psychiatric disorders, cognitive status, and sleep, in cervical dystonia (CD), hemifacial spasm (HFS), and blepharospasm (BPS) patients and to investigate whether these symptoms are related to the severity of motor symptoms.

METHODS

This was a single-center cross-sectional, observational, case-control study. Motor severity scales were used to determine disease severity. We evaluated non-motor symptoms with commonly used scales. A total of 73 patients and 73 control groups participated.

RESULTS

In CD patients, the MoCA total score, 'language', 'abstraction', and 'orientation' scores were statistically significantly lower; PSQI, ESS, and NMSQ scores were statistically significantly higher than controls. In the BPS group, the MoCA total score and the 'language' score were significantly lower, and the NMSQ score was statistically significantly higher than the controls. In the HFS group, MoCA total score, 'executive functions', 'language', and 'abstraction' scores were statistically significantly lower; PSQI scores are statistically significantly higher than controls. There was a positive correlation between the severity score and the PSQI score in the CD group and between the severity score and the NMSQ score in the BPS group. All three groups had significant cognitive impairments.

CONCLUSIONS

In CD, BPS, and HFS, non-motor symptoms are apparent with undeniable frequency in addition to common motor symptoms. Importantly, these NMS may cause significant deterioration in the quality of life of the patients.

Profile of patients with essential blepharospasm and hemifacial spasm in the two largest ophthalmology reference centers in Brazil

PURPOSE

Information is scarce regarding the comprehensive profile of patients with essential blepharospasm and hemifacial spasm in Brazil. The present study aimed to assess the clinical features of patients with these conditions, followed up in two reference centers in Brazil.

METHODS

The study included patients with essential blepharospasm and hemifacial spasm, followed up at the Departments of Ophthalmology at Universidade Federal de São Paulo and Universidade de São Paulo. Apart from demographic and clinical features, past stressful events related to the first symptoms (triggering event), aggravating factors, sensory tricks, and other ameliorating factors for the eyelid spasms were assessed.

RESULTS

A total of 102 patients were included in this study. Most patients were female (67.7%). Essential blepharospasm was the most frequent movement disorder [51/102 patients (50%)], followed by hemifacial spasm (45%) and Meige's syndrome (5%). In 63.5% of the patients, the onset of the disorder was associated with a past stressful event. Ameliorating factors were reported by 76.5% of patients; 47% of patients reported sensory tricks. In addition, 87% of the patients reported the presence of an aggravating factor for the spasms; stress (51%) was the most frequent.

CONCLUSION

Our study provides information regarding the clinical features of patients treated in the two largest ophthalmology reference centers in Brazil.

Evaluation of Blepharoptosis in Patients With Refractory Blepharospasm by VISA-Video Recordings, Idiosyncratic Expressions, Sensory Tricks, and Ancillary Procedures

BACKGROUND

How to evaluate blepharoptosis concomitantly presented with refractory and uncontrollable blepharospasm? To date, there is a paucity of publications on the ideal evaluation methods. An innovative method-video recordings, idiosyncratic facial expressions, sensory tricks, and ancillary procedures (VISA)-is developed for preoperative evaluation, and the surgical outcomes are demonstrated.

METHODS

A retrospective study using VISA for blepharoptosis evaluation was conducted on 51 patients with refractory blepharospasm. Based on the evaluation, patients underwent blepharoptosis correction simultaneously besides the selective myectomy and myotomy in situ of the eyelid protractors for blepharospasm. Preoperative and postoperative palpebral fissure height, margin reflex distance 1, ptosis severity, and levator function were assessed to identify the effectiveness of VISA. All the procedures were performed by the senior author C.-S.L.

RESULTS

There were 42 patients diagnosed with essential blepharospasm and 9 patients with Meige syndrome. Forty-one patients (82/102 eyelids [80.4%]) had concomitant blepharoptosis and blepharospasm. Ptosis severity was mild in 21 eyelids (25.6%), moderate in 12 eyelids (14.6%), and severe in 49 eyelids (59.8%). Preoperative/postoperative (6 months) values of palpebral fissure height, margin reflex distance 1, and levator function were 4.70 ± 2.45 mm/8.35 ± 1.33 mm (P < 0.05), -0.30 ± 3.19 mm/3.73 ± 1.05 mm (P < 0.05), and 13.07 ± 2.56 mm/13.68 ± 2.34 mm (P < 0.05), respectively. Undercorrection and revision rate reported 9.8% and 3.7%, individually.

CONCLUSIONS

VISA approach overcomes the difficulty of blepharoptosis assessment in patients with refractory blepharospasm. It provides useful preoperative information required for adequate blepharoptosis correction in blepharospasm surgery and yielded desirable outcomes.

[Mental disorders in blepharospasm]

OBJECTIVE

To analyze mental disorders in blepharospasm (BS) before and after botulinum therapy (BT).

MATERIAL AND METHODS

We examined 25 patients with BS (9 men and 16 women), aged 50 to 85 years (mean 64.1±18.5), with BS (main study group). The control group consisted of 20 healthy individuals (7 men and 13 women, mean age 63.5±8.5). Patients were examined before and after BT (after 3 weeks) using a diagnostic structured interview Mini International Neuropsychiatric Interview, GAD-7, PHQ-9, fear of negative assessment (short version) and The Liebowitz Social Anxiety Scale (LSAS).

RESULTS

Fifty-six percent of patients with BS, as assessed by the GAD-7, showed a high level of anxiety, while depression, measured by the PHQ-9 and found in 52% of patients, was mainly manifested by mild disorders. In the group of patients with BS, the mean scores were higher on the GAD-7, PHQ-9, fear of negative assessment (p<0.001) and LSAS (p<0.05) than in the control group. After treatment with BT, the levels of anxiety and depression in patients with BS decreased slightly and remained higher compared with the control group. Psychiatric examination in the majority (64%) of patients revealed mental disorders that could not be explained by the occurrence of BS. The remaining 36% of patients had adaptation disorders (nosogenic reactions) caused by BS. Affective mental pathology (recurrent depressive disorder and dysthymia) and anxiety disorders (social phobia and adjustment disorders) were more often observed in the main study group compared with the control group (24% versus 5% and 68% versus 10%, respectively).

CONCLUSION

A significant proportion of patients with BS have anxiety and depressive disorders, the severity of which does not depend only on the severity of motor symptoms and does not significantly decrease after successful BT, but is caused by mental disorders that preceded the manifestation of BS. Identification of mental disorders to varying degrees associated with BS, not only on the basis of psychometric scales, but also consultation with a psychiatrist, will allow, in addition to the correction of motor symptoms of BS, to differentiate the therapeutic approach through psychotherapy and psychopharmacotherapy.

Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm

OBJECTIVE

To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin.

METHODS

Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time (BUT), fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper.

RESULTS

100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The BUT was 7.2 ± 0.2 sg before and 7.5 ± 0.7 sg after treatment. Schirmer's test was 11.4 ± 5.5 and 12.5 ± 5.5 mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%.

CONCLUSION

Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are normal.

A case report of fulminant type 1 diabetes mellitus associated with drug-induced hypersensitivity syndrome in an elderly patient with coxsackie B4 virus infection and human leukocyte antigen-A24 haplotype

Drug-induced hypersensitivity syndrome (DIHS) is a severe systemic adverse drug reaction. Previous studies showed that DIHS is associated with the onset of fulminant type 1 diabetes mellitus (FT1D). Although genetic background and abnormalities in immune response or viral infection are considered to be associated with pathogenesis of FT1D, it remains unclear whether virus infection and specific human leukocyte antigen (HLA) typing are involved in DIHS-associated FT1D. Here, we report a case of a 78-year-old female patient with FT1D after DIHS treatment. She was diagnosed as DIHS caused by carbamazepine, and treatment with predonisolone was initiated. After 46 days from the occurrence of DIHS, she was admitted to our hospital because of type 1 diabetes mellitus and diabetic ketoacidosis. Although her Hemoglobin A1c (HbA1c) was elevated by predonisolone treatment (HbA1c: 9.2%), we diagnosed her as fulminant type 1 diabetes mellitus considering the abrupt onset of the ketoacidosis. Her general condition was improved by treatment with fluid infusion and insulin administration. During her clinical course, the infection of coxsackie B4 virus was observed. In addition, the examination of HLA typing showed HLA-A24 haplotype. These findings suggest that the coxsackie B4 virus infection may be involved in the pathogenesis of DIHS-induced FT1D, and that HLA-A24 haplotype might relate to DIHS-associated FT1D.

Frontalis suspension surgery to treat patients with blepharospasm and eyelid opening apraxia: long-term results

Blepharospasm may be accompanied by eyelid opening apraxia (EOA) reducing the efficacy of botulinum toxin (BT) therapy. The frontalis suspension operation (FSO) is then the only effective treatment option available. We want to report the first long-term results with FSO. We studied 15 patients with blepharospasm and EAO unresponsive to BT therapy (9 females, 6 males, age 61.9 ± 11.5 years). FSO was performed by applying 2 polytetrafluoroethylene threads (PTFE, Gore-Tex^®) per eye connecting the frontalis muscle to the upper eye lid. Tension of the two carrés was set to produce a palpebral fissure width of 2-3 mm. Therapy outcome was monitored by a quality-of-life questionnaire (QoL-Q) and a self-assessment calendar reviewing postoperative days 0-9 (T1), 10-89 (T2), 90-179 (T3), 180-365 (T4), and >365 days (T5). Altogether, 40 FSO were performed. Postoperatively, all patients reported improved eyelid opening, 4 (27%) complete remission of symptoms. At T1, this improvement was 74.6 ± 26.4% on the self-assessment scale, after 1 year 68.2 ± 27.5%. Throughout the observation period (T1-T5), the improvement was 71.9 ± 25.6%. All 19 items on the QoL-Q (except for presence of involuntary eye lid closure) showed postoperative improvement. Adverse effects included circumscript upper eyelid haematomas, suture extrusion, suture granuloma, lacrimation, and infections. In all patients, BT therapy had to be continued to treat orbicularis oculi contractions. Our first long-term results demonstrate that FSO is a benign procedure producing robust and stable therapeutic effects on EOA in blepharospasm.

Screening for Cognitive Impairments in Primary Blepharospasm

Backgrounds

Studies have reported that non-motor symptoms are an important component of primary dystonia. However, evidence supporting cognitive impairment in primary dystonia is limited and contradictory.

Methods

We applied the Chinese version of the Addenbrooke’s Cognitive Examination-Revised and the Mini-Mental State Examination (MMSE) to screen for cognitive impairment in patients with primary blepharospasm. In addition, we investigated the relationship between performance on the Addenbrooke’s Cognitive Examination-Revised and quality of life as measured by the Medical Outcomes Study 36-item Short-Form (SF36).

Results

The study included 68 primary blepharospasm patients and 68 controls matched by age, sex and education. The prevalence of cognitive deficits was 22.0% and 32.3% in primary blepharospasm patients group, as measured by the MMSE and the Addenbrooke’s Cognitive Examination-Revised, respectively. Primary blepharospasm patents had a broad range of cognitive deficits, with the most frequently affected domains being visuospatial function (30.9%) and language (30.9%), followed by memory (27.9%), orientation/attention (26.4%) and verbal fluency (22.0%). Patients with cognitive deficits had lower total SF36 scores, especially in the subdomains of physical functioning, role-physical and social functioning, compared to those without cognitive deficits. Scores on the Addenbrooke’s Cognitive Examination-Revised were significantly correlated with both the SF36 scores and the scores on the subdomains of physical functioning and social functioning.

Conclusions

Some patients with primary blepharospasm have cognitive deficits. Poor performance on the Addenbrooke’s Cognitive Examination-Revised is related to poorer quality of life.

Tear production and drainage after botulinum toxin A injection in patients with essential blepharospasm

PURPOSE

To evaluate the clinical manifestations of tear production, distribution and drainage in the essential blepharospasm patients, and to analyse the changes after botulinum toxin A injection in these patients.

METHODS

This prospective study was performed in 23 patients with essential blepharospasm treated with Botulinum neurotoxin A (BoNT-A; Dysport, Ipsen Biopharm, UK) from November 2010 to February 2011. Ocular examinations, including frequency and severity of blepharospasm, tear break up time (BUT), Schirmer's test, lower lid tear meniscus height (TMH) measured by optical coherence tomography (OCT, rtvue software version 3.5; Optovue Inc., Fremont, CA, USA), and dacryoscintigraphy using 99m technetium pertechnetate, were performed before and 2 weeks after BoNT-A injection. We asked all patients about changes in the dry eye symptom score, before and after treatment. Results were analysed with independent t-test using spss software version 12.0 for Windows XP, (SPSS Inc., Chicago, IL, USA).

RESULTS

Botulinum neurotoxin A treatment relieved blepharospasm in all patients. Mean injection dose was 38 ± 5.6 units. After injection, mean tear BUT was significantly increased from 4.7 ± 4.9 to 6.6 ± 1.6 seconds (p = 0.001) Lower TMH increased in all three points and most notably at the lateral point (p = 0.05). On dacryoscintigraphy, tear drainage velocity was not affected by BoNT-A treatment. But Tc-99m 50% clearance time in interpalpebral fissure significantly increased from 1564 to 2220 seconds on the time activity curve (p = 0.027). Subjective dry eye symptoms also improved in 16 patients (70%) after injection.

CONCLUSION

Tear film stability and TMH increased, but tear drainage velocity was not affected by BoNT-A treatment. Overall Tc-99m 50% clearance time in interpalpebral fissure significantly increased, and tear storage from mild lateral lower eyelid laxity increased after BoNT-A injection. Botulinum neurotoxin A injection was also effective for combined dry eye symptom in the essential blepharospasm patients.

Shedding light on photophobia

Photophobia is a common yet debilitating symptom seen in many ophthalmic and neurologic disorders. Despite its prevalence, it is poorly understood and difficult to treat. However, the past few years have seen significant advances in our understanding of this symptom. We review the clinical characteristics and disorders associated with photophobia, discuss the anatomy and physiology of this phenomenon, and conclude with a practical approach to diagnosis and treatment.

Botulinum toxin improves the quality of life and reduces the intensification of depressive symptoms in patients with blepharospasm

Blepharospasm (BSP) is a focal dystonia that results in hyperactivity of orbicular muscles of eyes. These symptoms often result in decreased quality of life (QoL) and symptoms of depression. Botulinum toxin type A is the current first line therapy. The aim of the present study was to analyze the impact of botulinum toxin treatment on the QoL and depressive symptoms in patients with BSP. The QoL was evaluated by means of the Short Form 36 questionnaire. The degree of the intensity of depression was evaluated by means of the Montgomery-Asberg Depression Rating Scale. Botulinum toxin treatment significantly improves the QoL and reduces the intensity of depressive symptoms in all our study patients with BSP.

Modified Lundie loops improve apraxia of eyelid opening

BACKGROUND

Current treatments are unsatisfactory for improving apraxia of eyelid opening, defined as a delay or inability to open closed eyelids voluntarily in the presence of intact motor pathways.

METHODS

Improvement in functional health was assessed using the Blepharospasm Disability Scale (BDS) in five consecutive patients with apraxia of eyelid opening treated with wire loops affixed behind ordinary spectacles (Lundie loops) and modified to provide pressure on the brow as a stimulus to keep the eyelids elevated.

RESULTS

All five patients showed improvement in BDS scores. The mean percentage of normal activity of the study population improved from 25% to 37.6%. Outdoor activities were not significantly altered with the use of the device.

CONCLUSIONS

Modified Lundie loops appear to be helpful in improving the functional health of patients with eyelid apraxia. These results will need to be verified in larger trials.

[Lacrimal film evaluation of patients with facial dystonia during botulinum toxin type A treatment]

PURPOSE

To determine the effect of botulinum toxin injection in the eyelid on lacrimal film in patients with facial dystonia.

METHODS

Twenty-four patients with essential blepharospasm and hemifacial spasm were submitted to botulinum toxin injection and lacrimal film tests were performed before the application and after seven and thirty days.

RESULTS

There was improvement in symptoms of dry eye and rose bengal test, however, the breakup time and Schirmer's test did not show significant variation between pretreatment and after 1 month of follow-up.

CONCLUSION

The dry eye symptoms in patients with facial dystonia may be attenuated by botulinum toxin due to its possible inhibitory effect on the orbicular muscle leading to a decrease in lacrimal pump.

Asynchronous blepharospasm, facial and cervical dystonia, and bilateral asynchronous hemifacial spasm

We present a patient with a facial movement disorder that has characteristics of both blepharospasm and bilateral asynchronous hemifacial spasm. Because of the increased incidence of blepharospasm in patients with hemifacial spasm, our patient's clinical presentation is probably not a chance occurrence, but rather a manifestation of some predisposition for these two movement disorders. This unusual constellation of signs and symptoms challenges the current diagnostic criteria and suggests that some of these facial movement disorders may lie on a spectrum, rather than represent distinct entities.

Meige syndrome and pallidal deep brain stimulation

The cause of primary Meige syndrome is unknown, and although gender and age predilections are different from idiopathic torsion dystonia, most investigators consider Meige syndrome a variant of that disorder. Interest in the use of stereotactic brain surgery for refractory forms of dystonia is thus increasing. There is little experience with the use of deep brain stimulation (DBS) in focal dystonias, and reports of its use in Meige syndrome are very rare. We report on a case of Meige syndrome successfully treated with bilateral pallidal DBS.

Silent event-related fMRI reveals deficient motor and enhanced somatosensory activation in orofacial dystonia

Previous studies showed cortical dysfunction and impaired sensorimotor integration in primary generalized and focal hand dystonia. We used a whistling task and silent event-related fMRI to investigate functional changes in patients with blepharospasm and patients with a combination of blepharospasm and oromandibular dystonia (Meige's syndrome). Whistling served as a model for a skilful orofacial movement with a high demand on sensorimotor integration. It allowed us to study the oromandibular motor system that is clinically affected in Meige's syndrome but not in isolated blepharospasm. In Meige's syndrome, functional MRI revealed deficient activation of the primary motor and ventral premotor cortex within the mouth representation area during whistling. Compared with healthy controls, both forms of orofacial dystonia had increased activation of bilateral somatosensory areas and the caudal supplementary motor area (SMA) in common. While overactivity of somatosensory areas and caudal SMA in Meige patients was partly reversed by botulinum toxin treatment, impaired motor activation was not. We conclude that impaired motor activation appears to be specific for the clinically affected oromandibular motor system in Meige's syndrome while enhanced somatosensory activation is a common abnormality in both forms of orofacial dystonia independent of the affected motor system. Somatosensory overactivity indicates an altered somatosensory representation in orofacial dystonia while impaired motor activation may be a functional correlate of reduced cortical inhibition during oromandibular motor execution in Meige's syndrome.

Remission of tardive dystonia (blepharospasm) after electroconvulsive therapy in a patient with treatment-refractory schizophrenia

Tardive dystonia is a movement disorder dominated by involuntary muscle contractions that may be tonic, spasmodic, patterned or repetitive, associated with the use of dopamine-receptor blocking agents. Most of the patients with tardive dystonia present initially with blepharospasm. Treatment of dystonia is generally disappointing. A patient with chronic paranoid schizophrenia who developed blepharospasm is described here. Blepharospasm remitted after a course of electroconvulsive therapy. Remission was sustained until 3 months after stopping maintenance electroconvulsive therapy.

Swallowing disorders in patients with blepharospasm

Blepharospasm is a focal dystonia characterized by involuntary eye closure due to abnormal contraction of orbicular eyelid muscles. When blepharospasm is associated to the presence of involuntary oromandibular movements, it is termed Meige syndrome. The aim of this study was to investigate the presence of deglutition alterations in patients with concurrent blepharospasm and Meige syndrome. Twenty consecutive patients were studied by video fluoroscopy using a barium technique. The 4 stages of deglutition were investigated. Ninety percent of patients (18 cases) presented deglutition disorders. The more commonly found alterations were premature food drop, 15 cases (83%) and vallecuale residuals, 14 cases (78%). Sixty seven percent of abnormal findings occurred in the third stage of deglutition. Eighty-nine percent of patients (16) presented more than one swallowing alteration. There was a positive and significant correlation between the number of alterations and patient's age or disease duration. Prevalence of swallowing disorders in the healthy elderly population is reported to be 44%. In our series it reached 90%, suggesting that our findings might be related not only with age but also with a more widespread dystonia exceeding the orofacial muscles.

Apraxia of lid opening: dose-dependent response to carbidopa-levodopa

A 67-year-old woman with an 8-year history of Parkinson's disease and Lewy body dementia experienced difficulty in opening her eyelids (apraxia of lid opening [ALO]); she could close them without difficulty. This problem emerged 2 weeks after the patient's dosage of carbidopa 50 mg-levodopa 200 mg 3 times/day was decreased to twice/day. Two weeks after the onset of ALO the patient visited her physician, who suspected carbidopa-levodopa of causing the problem; the drug was discontinued. When the patient's condition worsened rather than improved, she was referred to a neuro-ophthalmologist, who confirmed the diagnosis of ALO. However, the neuro-ophthalmologist noted that this may not have been a true apraxia but rather a form of sustained blepharospasm that prevented the eyelid from opening. Carbidopa-levodopa was restarted, and her condition improved dramatically when her dosage was increased gradually to carbidopa 50 mg-levodopa 200 mg in the morning and at noon, and carbidopa 25 mg-levodopa 100 mg in the evening. Clinicians should be aware of adverse reactions, such as AOL, in patients taking carbidopa-levodopa who have dementia of the Lewy body type.

Blepharospasm associated with multiple system atrophy: a case report and review of the literature

Although blepharospasm has been occasionally associated with parkinsonism, it has rarely been reported in patients with multiple system atrophy (MSA). We report a 65-year-old woman with MSA who developed blepharospasm seven years after onset, rendering her functionally blind. Clinical course and the findings of magnetic resonance imaging indicated cerebellar type MSA. The blink reflex studies showed prolonged R2 response and enhanced recovery cycle, indicating an increased excitability of the brainstem interneurons. These results suggest that pathophysiology of blepharospasm in MSA is similar to that of essential blepharospasm. Recognition of blepharospasm in MSA patients is important, as blepharospasm is a treatable feature in this otherwise intractable disorder.

Coexistent blepharospasm and hemifacial spasm: overlapping pathophysiologic mechanism?

BACKGROUND/AIM

Blepharospasm (BEB) and hemifacial spasm (HFS) appear to be distinct disorders. Clinical characteristics of coexistent BEB and HFS have not been examined. The aim of this study was to determine the prevalence, clinical, and imaging features of coexistent BEB among a cohort of HFS patients and controls.

RESULTS

Among 665 study subjects, nine (5.5%) of the 164 consecutive HFS patients had coexistent BEB, significantly higher than age and gender matched controls (0/501, 0%) without neurological diseases (p<0.0001). The mean age of the nine patients was 61.4 (SD 9.9) (range 51-72), consisting of 88.9% women, and 66.7% had left sided HFS, similar to HFS patients without BEB. Six (66.7%) reported BEB symptoms at a mean of 0.8 years after HFS onset, one before, and onset was undetermined in two patients. Advanced magnetic resonance imaging and angiography revealed neurovascular compression of the ipsilateral side of HFS, without any basal ganglia lesions.

CONCLUSIONS

BEB occurred more frequently in HFS patients, suggesting changes in the brainstem blink reflex circuitry could play a modulatory role in certain at-risk individuals resulting in the coexistence of these movement disorders.

[Cogan síndrome. Audio-vestibular findings in a patient and literature review]

Cogan Sindrome is described as the association of non-syphilic interstitial keratitis with vestibulo-auditory symptoms in its typical form. We are reporting a case corresponding to a 32 years old male who consulted at first place for ophthalmic clinic and, two months later, affected of bilateral neurosensorial hearing loss with tinnitus and vestibular dysfunction. In spite of the corticoid treatment our patient has not improved. His hearing disorder was even worse after one year-follow up. A bibliographic review has been performed related to this pathology whose etiology is still unknown.

Advancement of the frontalis muscle for ptosis of the brow associated with essential blepharospasm

We evaluated our results of advancement of the frontalis muscle to correct brow ptosis associated with blepharospasm in five patients who had difficulty opening their eyelids as a result of ptosis even after injections of botulinum toxin. The frontalis muscle was retracted inferiorly and connected directly to the skin of the eyebrow. Postoperatively the level of the eyebrow was raised above the superior orbital rim in all cases during the observation period (4 to 15 months). Although the operation did not improve muscle spasms, it successfully shortened the duration of involuntary closure of the eyelid. The only postoperative complication was lymphoedema of the eyelids. Results of postoperative injection of botulinum toxin were satisfactory. Advancement of the frontalis muscle corrects brow ptosis without major complications, and is complementary to injection of botulinum toxin.

[Blepharospasm in a patient with thymoma and positive anti-acetylcholine receptor antibody]

We report a rare case of a 70-year-old woman diagnosed as having blepharospasm with positive anti-acetylcholine receptor antibody. Blepharospasm developed in November, 2000, and increased in frequency, and worsened toward the evening. She complained of difficulty in her eyelid opening from October, 2002. Neurological examinations revealed blepharospasm and mild ptosis in both eyes. Tensilon test was negative. Waning and waxing were not detected in bilateral orbicularis oculi muscles by Harvey-Masland test. However, anti-acetylcholine receptor antibody was positive and thymoma in the anterior mediastinum was also found by the computed tomography of the chest. After the thymectomy, frequency of blepharospasm decreased. When blepharospasm worsened toward the evening, the co-existence of myasthenia gravis should be borne in mind.

Is acupuncture an useful tool for pain-treatment in ophthalmology?

Pain that does not respond to conventional treatment procedures makes it necessary to look for alternative methods. Acupuncture is an ancient procedure with empirical effects on pain. Previous studies established the increased output of messengers at neuronal junctions in spinal cord and hypothalamic locations, especially of endorphins which inhibit the perception of pain. We treated several painful symptoms with acupuncture and evaluated the outcome of the treatment. Patients with various kinds of therapy-refractory pain and patients in whom conventional treatment methods could not be applied were included in the study. The diagnoses included glaucoma. Tolosa-Hunt-Syndrome, ophthalmic migraine, blepharospasm, and dry eyes. In one case acupuncture was used for analgesia during surgery. Acupuncture was performed with sterile disposable needles, at points known to have an empirical analgesic effect. The stimulation was adapted to the patient's individual needs. VAS assessments before and after acupuncture were compared. The t-test was used for statistical evaluation. Acupuncture had no side effects, but reduced pain to a variable extent. Especially in cases of severe pain and in surgery, very effective pain reduction was achieved. In general, pain was significantly reduced in all patients by the use of acupuncture. A statistically significant effect was noted (p < 0.05). Further studies should be conducted to demonstrate the specific effect in larger patient populations. Monitoring neurotransmitter activity will possibly help to illustrate the effect.

Frequency of apraxia of eyelid opening in the general population and in patients with extrapyramidal disorders

We ascertained the prevalence of apraxia of eyelid opening (AEO) in a community located in Puglia, a region of southern Italy. The crude prevalence rate was 59 per million (95% confidence interval, 24-173). AEO coexisted with adult onset blepharospasm in 75% of cases, with atypical parkinsonism in 25% of cases. Among the overall patient population seen at our movement disorders clinic from 1987 to 1997, AEO was isolated in 10 otherwise healthy individuals, associated with adult-onset dystonia in 13 cases, and associated with a parkinsonian syndrome in 9 cases. The frequency of AEO was 10.8% in the dystonia group, and 2.1% in the overall parkinsonian group (Parkinson's disease, 0.7%; progressive supranuclear palsy, 33.3%). In two patients with possible progressive supranuclear palsy, AEO worsened after increasing levodopa dosage or acute apomorphine challenge and disappeared following levodopa discontinuation. AEO developing in the setting of a parkinsonian syndrome may be either disease- or drug-related.

The impact of blepharospasm and cervical dystonia on health-related quality of life and depression

The aim of the study was to evaluate and compare health-related quality of life (HR-QoL) and depression in essential blepharospasm (BSP) and idiopathic cervical dystonia (CD), to identify the clinical and demographic factors associated with poor HR-QoL in both disorders and to analyse the effect of Botulinum Toxin A (BtxA) therapy. Two hundred-twenty consecutive patients with BSP (N = 89, 62 % women, mean age 64 years, mean disease duration 7 years) and CD (N = 131, 64 % women, mean age 53 years, mean disease duration 8 years) recruited from routine referrals to eight Austrian dystonia clinics were included. HR-QoL was measured by the Short Form 36 (SF-36) and depression by the Beck Depression Inventory (BDI). At baseline, patients with CD and BSP scored significantly worse in all eight SF-36 domains compared with an age-matched community sample. In addition, 47 % of patients with CD and 37 % of those with BSP were depressed. Women with BSP scored significantly lower in all SF-36 domains and were more depressed than male patients. In contrast, there was no significant effect of gender on HR-QoL and depression in CD. Neck pain had a significant impact on all SF-36 domains and represented the main determinant of depression in CD. Although BtxA therapy resulted in a significant improvement of clinical symptoms in BSP and CD, HR-QoL did not improve in BSP and only two of the eight SF-36 domains improved significantly in patients with CD. The present study for the first time demonstrated that BSP has a substantial impact on health status emphasizing the need for psychological support with interventions aimed at treating depression in these patients. Our results provide further evidence for the profound impact of CD on HR-QoL and indicate the importance of an adequate management of neck pain in addition to reducing the severity of dystonia in CD. The mismatch between objective BtxA derived improvement of dystonia and lack of change of HR-QoL as determined by the SF-36 illustrates the need for optimized disease specific quality of life rating scales in patients with craniocervical dystonia.

Excessive blinking in childhood: a prospective evaluation of 99 children

OBJECTIVE

To determine the characteristics and causes of excess blinking in children and to determine outcomes after treatment.

DESIGN

Prospective, noncomparative, consecutive case series.

PARTICIPANTS

Ninety-nine consecutive children who presented for evaluation of excessive blinking over a 2 year period.

METHODS

Children less than 16 years of age who had excessive blinking as their sole or major chief complaint underwent detailed history and ophthalmologic examination. Treatment was recommended based on clinical examination findings. Follow-up evaluations were performed at least 2 months after initial examination.

MAIN OUTCOME MEASURES

Etiology of excess blinking and patient characteristics in each diagnostic group.

RESULTS

The majority (89%) of children presented with bilateral excessive blinking. Boys outnumbered girls at a ratio of almost 2:1. The most common etiologies were anterior segment and/or lid abnormalities (37%), habit tics (23%), uncorrected refractive errors (14%), intermittent exotropia (11%), and psycogenic blepharospasm (10%). A history of neurologic disease was present in 22% of the patients but was not causally related to the excessive blinking in most cases. Vision-threatening disease was noted in 6% and was easily detected on standard clinical examination. Life-threatening disease was the cause in 4% of the children, but the presence of life-threatening disease was already known in all such patients.

CONCLUSIONS

Excessive blinking in children can occur because of a large number of potential problems. Most cases are caused by benign and/or self-limiting conditions. The cause can usually be determined after careful history and clinical examination and routine neurologic evaluation and neuroimaging is unnecessary.

Blepharoclonus and Arnold-Chiari malformation

OBJECTIVE

Blepharoclonus (BLC) denotes a large amplitude, involuntary tremors of the orbicularis oculi muscles, observed during gentle closure of the eyelids. BLC may follow major head trauma. Four patients with Arnold-Chiari malformation (ACM) and BLC are described.

MATERIALS AND METHODS

The first patient had facial numbness for 5 months; the remaining patients had headaches following minor head or cervical spinal injuries. Brain magnetic resonance imaging (MRI), electroencephalogram (EEG) blink reflexes, mental and facial nerve responses and facial electromyogram (EMG) were performed.

RESULTS

All patients exhibited ACM on brain MRI. The first patient had coincidental dural venous malformation, empty-sella turcica and familial digital dysplasia. She exhibited oculopterygoid synkinesis. The last 3 patients had posttraumatic headache; the second and third patients had limited features of Ehlers-Danlos syndrome (EDS). The second patient had cervical spinal fusion and the fourth a cervical syrinx. All the patients had BLC on gentle eyelid closure.

CONCLUSION

BLC is an underdiagnosed neuro-ophthalmological sign of ACM.

[Blepharospasm and Meige's syndrome--a contribution to it's pathogenesis]

Two cases with blepharospasm followed by Meige syndrome were described. In the first magnetic resonants revealed bilateral hypodensive foci in thalamus. During the few years general dystonia has been developed after several relapses of disease diagnosed as multiple infarcts followed by aphasia, hemiparesis and asynergia. In the other one, who died, loss of neurons in striatum, especially in caudate nuclei was found. It is concluded that blepharospasm could be a syndrome of different origin and only the phase of Meige syndrome.

Synkinetic blepharoclonus

OBJECTIVES

To analyze the clinical data and test results collected in a group of patients exhibiting eyelid-closure blepharoclonus (BLC) on clinical neurologic examination.

MATERIALS AND METHODS

Thirty-five patients were referred for neurologic evaluation for reasons other than BLC. Clinical electrophysiologic evaluations, including cranial nerve testing and electromyograms, were done according to standards. All patients had neuroimaging studies, including brain magnetic resonance imaging and head computerized tomography, or both, and many had electroencephalograms. Additional tests were done based on the patient's symptoms or reasons for referral.

RESULTS

Eight patients had reflex BLC. Two cases were precipitated by vertical gaze; one of these patients had hereditary palmoplantar keratoderma and cataplexy, and the other patient had Ehlers-Danlos syndrome and familial BLC. Other precipitants included speech in four cases, postural changes in two cases, and light stimulation in one case. Two patients had generalized myoclonus independent of their BLC, two patients had a history of sleep myoclonus, and several patients had BLC-associated facial myoclonus. One patient had BLC-associated myoclonus of the right shoulder. Synkinetic cranial movements were detected in 11 patients (four oculofacial, three oculopterygoid, one oculolingual, two dual cases, and one case of imitation synkinesis.) Three patients had familial BLC, seven patients had congenital developmental disorders, six patients had synkinetic tremors, and six patients had restless feet. Some indication of peripheral neuropathy was evident in eight patients.

CONCLUSIONS

Eyelid-closure BLC is an underrecognized, sporadic or familial, mostly benign, chronic eyelid-movement disorder that may be associated with tremors, myoclonus, cranial synkinesis, and restless feet. Reflex mechanisms may be identified in some patients. Gaze-induced BLC seems to have the greatest clinical relevance. In the current series, there were no examples of posttraumatic BLC, multiple sclerosis, hydrocephalus, or blepharospasm conditions previously reported to be associated with BLC. No electroencephalographic abnormalities were recorded during BLC, ruling out eyelid-closure epilepsy.

Idiopathic blepharospasm does not lead to a parkinsonian syndrome: results of a questionnaire-based follow-up study

It has been suggested that a lesion in the dopaminergic neurons of the substantia nigra pars compacta combined with eye irritation is involved in the pathophysiology of idiopathic blepharospasm. If so, these patients might be prone to develop Parkinson's disease or a parkinsonian syndrome. We therefore conducted a validated questionnaire-based follow-up study to estimate (a) the frequency of local eye disorders at onset and (b) frequency of development of parkinsonian symptoms in blepharospasm patients. Ninety-nine patients previously diagnosed with idiopathic blepharospasm were sent a two-part questionnaire to assess parkinsonian and other symptoms associated with their condition. The average period of follow-up was 12.7 years, ranging from 3 to 26 years, with an average age at onset of 53.5 years. Sixty-two patients reported other ocular symptoms prior to or at the onset of blepharospasm, and therefore ocular disease may act as a trigger to produce blepharospasm in those already predisposed. Only two patients had developed a score on the parkinsonism rating scale indicating possible Parkinson's disease, but clinical examination confirmed this not to be the case. If a lesion in the dopaminergic neurons is involved in blepharospasm, it would appear to be relatively minor (and non-progressive), since patients with idiopathic blepharospasm do not seem prone to develop parkinsonian symptoms.

[Method of prevention and treating the accommodation cramp and progressive myopia in children]

A new method for treating the accommodation cramp and progressive myopia in children consists in transferring the glance from a close TV screen to a far one. One of the tasks of this method is to turn a computer game from a factor deteriorating the accommodation into a factor improving it. The picture is automatically transferred from one TV to the other every 10 seconds. Sixty-five children were followed up. The volume of relative accommodation improved, the progress of myopia in a year was 0.045 versus 0.5 diopters in the control group.

Headache and facial pain responsive to botulinum toxin: an unusual presentation of blepharospasm

The diagnosis of blepharospasm is rarely considered in patients complaining of face pain or headache. This patient illustrates the importance of looking for blepharospasm in patients who present with headache or face pain, as her pain and blepharospasm were successfully treated with botulinum toxin type A injections.

Botulinum toxin increases tearing in patients with Sjögren's syndrome: a preliminary report

Three patients with Sjögren's syndrome (SS) who had severe xerophthalmia and blepharospasm received botulinum toxin injections for the treatment of their blepharospasm. They had a remarkable increase in tearing, measured by Schirmer's test, and a decrease in signs and symptoms of dry eyes after botulinum toxin injection periorbitally for blepharospasm. The mechanism for this increased tearing is unclear, but suggests a potential treatment for patients with severe xerophthalmia with SS.