Frontalis suspension in the treatment of essential blepharospasm unresponsive to botulinum-toxin therapy: long-term results

Thirty-one patients with essential blepharospasm or lid opening disorder of the levator-inhibiting type, unresponsive to treatment with botulinum toxin, underwent frontalis suspension. Twenty-eight patients received bilateral surgery (three patients with bilateral complaints of different severity were operated on the more affected side; these patients were not included in the statistical analysis). The mean age was 62.4 years±8.52 (range 42–80 years). The individual improvement of complaints was assessed by the patients using a percentage scale (0%=no improvement; 100%=no complaints). Objective and subjective improvement was achieved in 26 of 28 patients. The mean subjective improvement was 57.7%±31.4. In 23 cases an additional treatment with botulinum toxin was administered. During follow-up period (mean 22.1 months±11.6; range 5–40 months) the effect of surgery remained stable. There were no serious complications, in a 5 of 56 operated eyes suture granuloma had developed. Unlike other surgeries for treatment of blepharospasm (excision of the orbicularis muscle, resection of facial nerve branches) frontalis suspension can be considered as a minimally invasive, but very effective and (if desired) reversible procedure. Moreover, additional treatment with botulinum toxin can bring about further improvement.     

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.     

Frontalis suspension combined with blepharoplasty as an effective treatment for blepharospasm associated with apraxia of eyelid opening

PURPOSE: Essential blepharospasm can be associated with apraxia of eyelid opening and is characterized by the inability to initiate the act of eyelid elevation even after cessation of orbicularis spasms. Current therapies such as botulinum toxin injections, orbicularis resection, or neurectomy may be unsuccessful or have undesired side effects. METHODS: Frontalis suspension was used to treat 13 consecutive patients with apraxia and blepharospasm during a 4-year interval. Follow-up ranged from 16 months to 55 months. To improve the aesthetic outcome, an upper blepharoplasty was done at the same time as the frontalis suspension in 7 cases. RESULTS: Good or excellent functional results were obtained in 10 of 13 patients. In 6 of these patients, the spasm disappeared completely. Therapy was unsuccessful in 1 patient, and in 2 patients blepharospasm recurred after 9 months. CONCLUSION: Patients with blepharospasm and apraxia of eyelid opening may benefit from a frontalis suspension operation, which can be considered minimally invasive and reversible.     

Apraxia of eyelid opening: clinical features and therapy

PURPOSE: Botulinum toxin injection is the treatment of choice in cases of benign essential blepharospasm. However, about 10% of the patients do not get sufficient effect from this treatment, and many of them have concomitant apraxia of lid opening. METHODS: Over a 3-year period we treated 12 patients. Three had pure apraxia of lid opening and in the other nine it was associated with blepharospasm. All patients were initially treated with botulinum toxin injections with poor results. They underwent surgical treatment like blepharoplasty, limited myectomy, aponeurosis repair, and/or frontalis suspension. Some of them needed post operative botulinum toxin injections in the pretarsal part of orbicularis oculi muscles. RESULTS: This combined therapy gave good functional and aesthetic results. CONCLUSIONS: The specific causes of blepharospasm and apraxia of lid opening are unknown, but these two conditions coexist in some patients and can be difficult to treat. It is important to make a correct diagnosis, and a combined surgical and botulinum toxin treatment can be very effective.     

Botulinum toxin A treatment in patients suffering from blepharospasm and dry eye

BACKGROUND: Many patients with essential blepharospasm also show dry eye signs and symptoms. Botulinum toxin A is an effective treatment for reducing spasms in these patients. In this investigation, the effect of botulinum toxin A injections on tear function and on the morphology of the ocular surface in patients suffering from blepharospasm in combination with a dry eye syndrome was investigated. METHODS: Botulinum toxin A injections were applied to 16 patients with blepharospasm. All patients complained of dry eye symptoms and had reduced tear break up time values. A subjective questionnaire and ocular examinations including tear break up time, Schirmer test without local anaesthesia, and rose bengal staining were evaluated before, 1 week, 1 month, and 3 months after injection. Impression cytology was performed before, 1 month, and 3 months after botulinum toxin A treatment. RESULTS: Although all patients were relieved of blepharospasm after botulinum toxin injections, only three noticed an improvement in dry eye symptoms. Eight patients noticed no difference and five complained of worsening. Tear break up time was found to be increased 1 week and 1 month after injections. Schirmer test measurements were reduced up to 3 months. Rose bengal staining slightly increased 1 week after injections. Impression cytology showed no definite change in conjunctival cell morphology 1 month and 3 months after botulinum toxin A injections. CONCLUSION: In the patients presented here suffering from blepharospasm and dry eye, botulinum toxin A injections were effective in relieving blepharospasm but were not successful in treating dry eye syndrome.     

Treatment of blepharospasm with medication, surgery and type A botulinum toxin

A total of 39 patients with essential blepharospasm and 2 patients with hemifacial spasm were treated with one or more forms of therapy. All patients underwent neurologic and ophthalmic assessment to rule out ocular causes of blepharospasm. Thirty-six patients were given a trial of various medications. Only one patient was successfully treated: her condition was markedly improved with pimozide after benztropine mesylate, clonazepam and amantadine hydrochloride had failed to help. Patients who did not respond to drug therapy were offered the option of undergoing eyebrow-eyelid muscle stripping surgery. The six patients who underwent surgery showed considerable improvement; however, side effects such as frontal anesthesia, exposure keratitis, lagophthalmus, scarring and eyelid malposition occurred, and three of the six had residual spasm. At this point type A botulinum toxin became available. A total of 27 patients (26 who did not respond to drug therapy, including the 3 with residual spasm after surgery, and 1 previously untreated patient) received type A botulinum toxin injections. Most experienced rapid relief from their spasms. The beneficial effects lasted weeks to months, and there were no major side effects. Treatment with type A botulinum toxin appears to be a safe and effective means of temporarily relieving blepharospasm. The long-term results with repeated injections are yet to be determined.     

Efficacy of Carbamazepine Combined with Botulinum Toxin A in the Treatment of Blepharospasm and Hemifacial Spasm

 Purpose: To observe the efficacy of the combined treatment of carbamazepine and botulinum toxin A for blepharospasm and hemifacial spasm. Methods: Fifty-eight patients with either blepharospasm or hemifacial spasm were randomly divided into treatment and control groups. In the treatment group, 30 patients were administered with local intramuscular injections of botulinum toxin A and oral carbamazepine 100 mg/time,3 times/day for 60 days. Twenty-eight subjects in the control group underwent local intramuscular injections of botulinum toxin A only. Results: After combined treatment, the complete remission rate was 90%, which was significantly higher than that of the of the control group (67.9%, P<0.05，X2=4.733). However, no statistical significance was noted regarding the duration of therapeutic effects between the treatment group (range 14~40 weeks; 19.2 weeks on average) and control group (range 12~36 weeks; 18 weeks on average). Conclusion: The combined therapy of carbamazepine and topical injections of botulinum toxin A had increased efficacy in the treatment of blepharospasm or hemifacial spasm, but had no significant effect in terms of the duration of the therapeutic effect.     

Treatment of blepharospasm with botulinum neurotoxin type A: long-term results

PURPOSE: To describe the long-term efficacy and side effects of treatment of blepharospasm with botulinum neurotoxin type A (Botox). METHODS: A total of 178 patients with blepharospasm were treated by injections of botulinum toxin in the Eye Clinic of the University of Naples from 1980 to 2001. The severity of spasm for each patient was graded on a four-point scale. Duration of improvement was assessed and reported in months. RESULTS: Of 178 cases, 10 were lost to follow-up; of the remaining patients, 93% reported improvement after treatments. The mean duration of improvement was 3.6 months. Twelve patients (76%) who underwent more than 14 treatments maintained stable relief. Three patients (1.7%) had a total remission of spasms. Side-effects were local; none of the 168 patients experienced any systemic or toxic reaction. CONCLUSIONS: Botulinum toxin therapy for blepharospasm can provide long-lasting relief and reduction of spasms in the majority of patients. This therapy has the advantages of being safe, simple, and repeatable.     

Long-term results and complications of botulinum A toxin in the treatment of blepharospasm

The authors review their long-term results and complications with the use of botulinum A toxin in the treatment of facial dystonias. Two hundred thirty-two patients in three diagnostic groups--essential blepharospasm, hemifacial spasm, and Meige's syndrome--were treated with botulinum A toxin. A total of 1044 treatments were given over a 4-year period. A reduction in orbicularis spasm intensity was noted in 1012 (96.9%) treatments (mean duration, 13.3 weeks). There was no clear relationship between toxin dose and the amount of spasm reduction or duration of response, and average duration of beneficial effect remained constant from the first through the twelfth injections. Complications occurred in 236 (22.6%) treatments. In most cases, these were local and transient. Symptomatic dry eye was the most common side effect, noted in 7.5% of cases. Ptosis was reported in 7.3% of treatments and photophobia in 2.5%. Diplopia involving the inferior oblique or lateral rectus muscles was seen in less than 1% of cases. There were no differences in degree of response or in complications among the three diagnostic groups, although there was a slight difference in duration of effect. Patients who had undergone previous eyelid surgery for blepharospasm did not respond differently from those without prior surgery.     

Pain relief in patients receiving periocular botulinum toxin A

PURPOSE: We hypothesized that patients with benign essential blepharospasm and hemifacial spasm experience relief of headache and eye pain after botulinum toxin injections. METHODS: A retrospective chart review of 85 patients who had received botulinum toxin injections at the University of Minnesota for treatment of benign essential blepharospasm and hemifacial spasm was conducted. A prospective telephone questionnaire was used to ascertain details regarding improvement of headache and eye pain. RESULTS: Of the 85 patients (34 men, 51 women), 20 patients (23.5%) had headaches and 29 (34.1%) had eye pain. Ten of 20 (50.0%) headache-positive patients and 24 of 29 patients (82.8%) with eye pain had reduction in their pain after botulinum toxin injections. CONCLUSION: The findings of this study support the use of botulinum toxin for headache and eye pain relief in patients with benign essential blepharospasm and hemifacial pain. In addition, with the expanding uses of botulinum toxin, the results support its antinociceptive effects. Further investigation should continue in the mechanism of botulinum toxin's effects on pain.     

Assessment of blepharospasm surgery using an improved disability scale: study of 138 patients

PURPOSE: To assess a new scale for grading functional disability in a series of patients operated on for blepharospasm resistant to treatment by botulinum toxin (BT) injections. METHODS: The bicentric study included 138 patients: 80 (58%) with essential blepharospasm; 46 (33%) with apraxia of eyelid opening; and 12 (9%) with intermediate forms. They had undergone orbicularis myectomy (92 cases, 67%), frontalis suspension (31 cases, 22%), or both (15 cases, 11%). Functional disability was assessed by using an original scale covering 6 daily life activities, each graded using 5 levels from 0 (no disability) to 4 (activity impossible). The score obtained was related to the total of activities actually performed to produce a functional disability score (FDS) from 0 to 100. Each patient's FDS was prospectively determined, before surgery and 3 months after surgery (M3). In patients who, after surgery, required a further course of BT injections, the FDS was assessed immediately before the third injection. RESULTS: The mean FDS fell significantly, from 78 +/- 15 (standard deviation) before surgery to 45 +/- 21 at M3 (p < 0.01%), whatever the clinical form of essential blepharospasm or surgical procedure. The mean postoperative FDS was significantly lower in the 62 patients (45%) weaned off BT than in the unweaned group, respectively (31 +/- 17 versus 56 +/- 18; p < 0.01). In the latter group, the mean FDS after BT reinjection (34 +/- 19) fell to a level comparable with that of the weaned patients. CONCLUSIONS: This accurate, easy-to-use scale makes it possible to quantify in patients with blepharospasm functional improvement as the result of surgery and, where applicable, of BT reinjection.     

肉毒毒素治疗眼睑、面肌痉挛的临床疗效

目的 肉毒毒素治疗眼睑、面肌痉挛的临床疗效及其应用。方法 应用肉毒毒素对眼睑、面肌痉挛患者进行局部肌肉多点注射法。结果 21例眼睑、面肌痉挛经注射肉毒毒素，大部分完全缓解或明显缓解，仅少部分为部分缓解，有效率达100％。全部病例均未出现全身毒副作用，局部并发症有轻微上睑下垂，均于治疗后3～4周自然恢复。结论 肉毒毒素局部注射为眼睑、面肌痉挛患者提供了一个安全、有效、可靠的治疗方法，值得临床推广使用。     

Treatment selections of 239 patients with blepharospasm and Meige syndrome over 11 years.

BACKGROUND: A retrospective review of 239 patients with benign essential blepharospasm and Meige syndrome was performed in order to determine patients' long term treatment preferences. METHODS: Of 239 patients evaluated, 228 received local injections of botulinum toxin, type A, into the eyelid and facial musculature over 11 years. RESULTS: Of 228 patients, 202 (72.1%) were still treated with botulinum toxin, type A. Eighteen patients (6.9%) no longer received botulinum toxin injections and sought no other treatment. Five patients (2.2%) had apparent remission of their disease after injection. Three patients (1.3%) ultimately obtained relief from orbicularis muscle extirpative surgery and required no additional treatment. Two of the 11 patients (4.6%) who chose not to receive botulinum toxin injections were successfully treated with other modalities: psychotherapy (one patient) and oral haloperidol (one patient). CONCLUSION: While botulinum toxin is the most highly effective treatment for benign essential blepharospasm and Meige syndrome over a long period of time, adjunctive oral drug therapy, including minor tranquillisers as well as eyelid surgery, may augment its effectiveness.     

Botulinum Toxin Therapy in Congenital Blepharospasm

Botulinum toxin injections are the treatment of choice for the management of essential blepharospasm in adults. No cases of congenital blepharospasm have been described in the literature so far, and no cases of botulinum toxin injection in an infant have been reported. A 4-week-old girl was referred to our department with absent eye opening and spasmodically closed eyes. Pregnancy and delivery had been normal. A neuropediatric examination did not reveal useful findings. A periorbital injection of botulinum toxin was performed at the age of 2 months to prevent deprivation amblyopia. Four days later, clearly visible bilateral eye opening and commencement of eye contact were observed. At the age of 3 years, her eyelids remain open and no side effects of botulinum toxin therapy have occurred.Key words: Congenital blepharospasm, Botulinum toxin, Child     

Long-term treatment of involuntary facial spasms using botulinum toxin

Botulinum toxin, a powerful pre-synaptic neurotoxin produced by Clostridium botulinum, interferes with the release of acetylcholine from nerve terminals. Since September 1985, we have been using this toxin to treat altogether 62 patients with benign facial spasms. Most of the patients had been on drugs or psychotherapy, 2 had received alcohol injections, 2 had undergone surgery of the orbicular branch, and 2 electrocoagulation of the facial nerve. In essential blepharospasm the duration of the beneficial effect after each treatment with botulinum toxin was about 3 1/2 months. In patients with hemifacial spasm the response was clearly longer, nearly 5 months in most cases. The treatment gave the best and longest-lasting relief of symptoms in patients suffering from disturbing myokymia. Response was poorest in patients suffering from facial spasms who simultaneously had a severe psychiatric disease. The most frequent side effect was mild or moderate ptosis (22.6%). Some patients complained of dry eyes and a few cases displayed facial nerve paresis. Side effects caused by botulinum toxin injections are transient but so also, unfortunately, is the beneficial effect on facial spasms.     

Efficacy and side effects of botulinum toxin treatment for blepharospasm and hemifacial spasm

Purpose : To analyse the effectiveness and rate of side effects of botulinum toxin treatment for blepharospasm and hemifacial spasm.
Methods : In a prospective trial, 81 patients with blepharospasm and 70 with hemifacial spasm were treated with botulinum toxin A in the neuro-ophthalmology clinic at St Vincent's Hospital, Melbourne. Some 989 treatments were given and the mean follow-up time was 28.7 months.
Results : The duration of action was longer for patients with hemifacial spasm than for those with blepharospasm (median 12.0 weeks compared with 7.0 weeks, P <0.0001). There was no change in the duration of effect over time with repeated treatments of the same dose (F = 0.4, P > 0.05). Once an effective dosage was reached, increasing the dose further did not prolong the duration of effect. There were no systemic side effects, but there were a number of local transient side effects. The most significant side effect was ptosis, which occurred in 12% of treatments given to those patients with blepharospasm and hemifacial spasm.
Conclusion : Botulinum toxin is an effective treatment for blepharospasm and hemifacial spasm, but there are a number of side effects, the most significant being ptosis.     

Treatment of blepharospasm with botulinum toxin

In 43 patients (81 eyes) with blepharospasm resistant to other forms of therapy, 149 outpatient injections of botulinum A toxin were given into the orbicularis oculi muscle. Subsequent follow-up periods ranged from ten to 210 days. Orbicularis oculi spasm, eyelid forced closure, and eyebrow spasm all decreased substantially over the first ten days following the initial injection. Patients with essential blepharospasm, hemifacial spasm, or previous surgery all responded in a similar fashion. This beneficial effect was transient, however, and additional treatment was required for sustained relief. Twenty-five patients received multiple injections with a mean interval of 65 days. Results of second and third injections were similar to the first in rapidity of onset and duration of effect. Complications were local, mild, and transient, and no systemic side effects were noted.     

Evaluation of polytetrafluoroethylene suture for frontalis suspension as compared to polybutylate-coated braided polyester

PURPOSE: To evaluate the efficacy of polytetrafluoroethylene (Gore-Tex) suture as compared to polybutylate-coated braided polyester (Ethibond) suture as sling materials for frontalis suspension in bilateral congenital ptosis. METHODS: Frontalis sling surgery by modified Crawford's double triangle technique was performed on 30 patients (60 eyes) with bilateral ptosis. The patients were randomized into two groups depending on the type of suture material used: polytetrafluoroethylene or braided polyester. RESULTS: Polytetrafluoroethylene suture achieved a statistically significant better and more stable ptosis correction, with slightly more lagophthalmos, than braided polyester suture over a mean (+/- SD) follow-up period of 16 +/- 3.24 months. There were more postoperative complications with braided polyester suture, but the difference was not statistically significant. CONCLUSION: This is the first clinical study in which polytetrafluoroethylene in the form of suture has been studied. Polytetrafluoroethylene suture was found to be a safe and effective sling material for frontalis suspension and it can be recommended for clinical use.     

额肌瓣悬吊术治疗完全性上睑下垂临床观察

目的 观察额肌瓣悬吊术治疗完全性上睑下垂的治疗效果。方法 对18例（21只眼）完全性上睑下垂患者施行额肌瓣悬吊术。平均随访18个月，观察其睑裂高度、上睑弧度、闭眼状态和角膜情况。结果 15例（17只眼）效果理想，3例（4只眼）效果显著，总有效率100％。结论 额肌瓣悬吊术治疗完全性上睑下垂效果良好，并有其独特优势。     

A型肉毒素治疗特发性眼睑痉挛临床报告

目的 观察A型肉毒素治疗特发性眼睑痉挛的效果及副作用.方法 选择因面神经功能紊乱而致的严重眼睑痉挛患者32例,皮下注射A型肉毒素,对治疗前后的病情分级进行对比,分析治疗效果.结果其中29例(90.62 %)患者在注射后眼睑痉挛完全缓解,3例(9.38 %)得到明显缓解,有效率100%.23例(71.88 %)患者3~5...