Bell's palsy and intraocular pressure.

A prospective study was established to test the effect of orbicularis tone on intraocular pressure. Local nerve block of the 7th cranial nerve by either the methods of Van Lint or O'Brien and Atkinson revealed no effect on the measured intraocular pressure.     

Robert E. Wright and the development of facial nerve akinesia

The name of Auguste Van Lint is linked with the development of facial nerve akinesia for ophthalmic surgery. Less well known is Robert Ernest Wright (1884–1977) who described techniques to block the facial nerve in the same manner as later published by Atkinson and Nadbath. This paper reviews Wright's life as an ophthalmologist and ophthalmic bacteriologist and pathologist in British India, and his role in the evolution of facial nerve akinesia.     

Orbicular synkinesis after facial paralysis: Treatment with botulinum toxin

Involuntary lid closure not rarely accompanies aberrant regeneration of nerve fibers after different types of facial paralysis. 23 patients with such synkinesis were treated with botulinum toxin injections into the orbicularis oculi muscle. After periocular injections all patients showed much improvement: a period of, on the average, 13 symptom-free weeks was followed by a period of minimal symptoms. There were only minor complications. Whenever repeated treatment is necessary, botulinum toxin proves to be an effective therapy for involuntary lid closure after defective healing following facial paralysis.     

Facial nerve akinesia

In ophthalmology, increasing attention has been directed to methods of local anesthesia and akinesia that provide complete analgesia and immobilization of the eye conducive to work with the surgical microscope, particularly in operations for cataracts. The volume of anesthetic agent often used to achieve these goals may approach the toxic level of the drug in some patients. A method of producing akinesia of the temporal, zygomatic, and buccal divisions of the facial nerve that requires only a small volume of anesthetic is described. In our experience, this method can, in many cases, provide akinesia of the orbicularis oculi equal in effect to some established methods of infiltrative akinesia that require large doses of anesthetic.     

Surgical repair of paralytic lagophthalmos by medial tarsal suspension of the lower lid.

BACKGROUND: The seventh nerve palsy causes loss of function in the affected orbicularis oculi muscle. There is exposure and dessication of the corneal surface and obvious aesthetic changes in facial symmetry. METHOD: A surgical procedure has been used in 11 patients to substantially improve palpebral closure. The technique consists of a small upper lid tarsoconjunctival flap sutured into a nasal pretarsal pocket of the lower lid, achieving a medial tarsal suspension of the lower lid. RESULTS: This technique improves cosmesis, is reversible, and combinable with other procedures. The signs and symptoms of exposure keratitis are satisfactorily resolved. There have been no complications in an average follow up of 5 1/2 years after this surgical procedure. CONCLUSION: This technique could be considered an appropriate treatment for patients suffering temporary or permanent facial palsy.     

Effect of hyaluronidase on ocular motility and eyelid function in sub-Tenon's anaesthesia: randomised controlled trial

PURPOSE: To assess the effect of hyaluronidase on eye and eyelid movements when used as an adjunct in sub-Tenon's anaesthesia. METHODS: A total of 60 patients who had sub-Tenon's anaesthesia prior to phacoemulsification surgery were divided into two equal groups in a double-masked randomised controlled fashion. Of these, Group A had 4 ml lignocaine 2%, while Group B had 4 ml lignocaine 2% with the addition of sodium hyaluronidase 75 IU/ml. Ocular motility, levator, and orbicularis oculi function were measured in all patients at 5 and 8 min. Levator function was scored from 0 (no function) to 3 (complete function) while orbicularis function was scored from 0 to 2. The score for ocular motility was the sum in four positions of gaze, each position scoring from 0 to 2. Results were compared using a nonparametric test. RESULTS: Group B achieved significantly better ocular and lid akinesia than Group A both at 5 and 8 min with P<0.01. The median scores for levator function at 5 and 8 min were 2 for Group A and 0 for Group B. For orbicularis function, the median scores at both time intervals were 2 for Group A and 1 for Group B. For ocular motility, the median score for Group A at 5 min was 3 and at 8 min was 2.5; for Group B at 5 min was 0.5 and at 8 min was 0. CONCLUSIONS: The addition of hyaluronidase in sub-Tenon's anaesthesia has a significant effect in improving ocular and lid (levator and orbicularis) akinesia.     

Associated facial contractions after seventh nerve palsy mimicking jaw-winking

A 51-year-old woman who had recovered from Bell's palsy complained of closure of her right eyelids synchronous with chewing. Examination revealed the closure to be synchronous with contraction of the orbicularis oris muscles, not jaw muscles. Other associated facial movements were detected. Electromyography demonstrated that the decrease in size of the palpebral fissure is from contraction of the orbicularis oculi muscles, not inhibition of the levator muscle, proving that this is the effect of aberrant seventh nerve regeneration. This is one of many mass action effects which can occur with seventh nerve regeneration and should not be termed a syndrome.     

Quantitative measurement of upper eyelid movements

A simple and noncontact method for recording upper eyelid movement by means of a solid state image sensor has been developed. Physiological parameters of blink and lid movements during gaze change were studied in 30 normal subjects. Maximum velocity against lid displacement was analyzed. Electromyography (EMG) of the levator palpebrae as well as orbicularis oculi muscles was conducted and vertical eye movement was recorded by electrooculography (EOG). The maximum lid velocity both for upward and downward gaze change was measured; it was always faster in the downward than in the upward gaze. The duration of lid movement during upward gaze change was about 70 msec longer than that of the vertical saccadic eye movement. By EMG, a pulse-step discharge has been well known to occur in the superior rectus muscle but it was never seen in the levator palpebrae muscle in the present observation. The maximum lid velocity of downward spontaneous blink showed two-phase distributions: phase 1 with an initial flat phase in small displacement and phase 2 with a steep phase in large displacement. By EMG, only the pretarsal portion of the orbicularis muscle discharged at the initial phase; preseptal as well as pretarsal orbicular muscle discharges were noted in the second phase. The simplicity of this technique would permit its wide clinical application.     

Needle‐based blocks for the 21st century ophthalmology

Acta Ophthalmol. 2011: 89: 5–9

Abstract.

Purpose: This paper reviews history of the needle orbital blocks used in the earlier centuries and how they have evolved towards safer anaesthesia in the modern clinical practice. Methods: Material is derived from literature searches from major ophthalmic and anaesthetic journals on the use of orbital needle blocks over earlier centuries. Results: Needle‐based anaesthetic techniques were described shortly after the invention of reliable medical needles. Atkinson popularized the classical retrobulbar block in a series of papers published in the early 20th century. This technique,which utilises a relatively long needle inserted towards the apex of the muscle cone behind the globe, has been criticized by some as unsuitable for modern 21st century ophthalmic surgery because of the extremely rare potential for serious complications. Satisfactory anaesthesia and akinesia can be obtained with short sharp or dull needles with slightly higher volumes of local anaesthetic agent placed in the farthest inferotemporal quadrant. Conclusion: Aside from relative safety, modern needle blocks offer the advantage of lid akinesia without a need for a second injection for the seventh nerve that is often performed con‐comitantly with retrobulbar block.     

Orbicularis oculi muscle in children. Histologic and histochemical characteristics.

This is the first study devoted to the histologic and histochemical characteristics of the orbicularis oculi muscle in children to the authors' knowledge. The orbicularis muscle was compared with extraocular, facial, and limb striated muscle. Light microscopy showed the orbicularis oculi muscle to be much smaller and more loosely packed than skeletal limb muscles. It further showed these muscle fibers to have greater variation in fiber size and shape and more endomysial and perimysial connective tissue. Finally, analysis of the histochemical reactions showed the orbicularis oculi had a higher percentage of fast-contracting fibers (Type II). This study establishes the histologic and histochemical standard characteristics for the orbicularis oculi muscle in children. It was found that orbicularis oculi muscles have some histologic and histochemical features in common with other facial muscles and other features in common with extraocular muscles.     

The effects of tetanus toxin on the orbicularis oculi muscle

PURPOSE: Tetanus toxin can cause localized neuromuscular weakness, but it also can produce systemic tetany. The action of tetanus toxin on the orbicularis muscle has not been studied in animals immunized to prevent systemic tetany. Our objective was to determine whether tetanus toxin could be used to treat orbicularis oculi muscle spasms. METHODS: We analyzed the clinical, electrophysiologic, and histopathologic effects of tetanus toxin injected into the orbicularis oculi muscle of rabbits with passive immunity to tetanus toxin. In six rabbits, the orbicularis oculi function in both eyes was assessed clinically, and the baseline orbicularis oculi muscle action potential was measured physiologically with electromyography (EMG). The rabbits then were immunized against tetanus toxin with tetanus immunoglobulin for immediate and definitive immunity. Tetanus toxin was injected into the left orbicularis oculi muscles, leaving the right eyes as controls. Ten days later, the rabbits were again assessed by clinical examination and with EMGs on both the injected side and the noninjected side. The animals were killed at 14 days, and the orbicularis muscle was removed from both sides. The injected and control tissues were examined microscopically for signs of neuromuscular denervation. RESULTS: All six rabbits showed weakness in eye closure on the side injected with tetanus toxin. In addition, four rabbits developed complete ear ptosis on the tetanus toxin injected side because of spread of the toxin to adjacent ear muscles. EMGs showed both a denervation of the orbicularis oculi muscle and a poor blink potential on the side injected with tetanus toxin. Histopathologic studies of the orbicularis oculi muscle injected with tetanus toxin showed angulation of both slow and fast types of muscle fibers compatible with neuromuscular denervation. CONCLUSIONS: Tetanus toxin can cause localized orbicularis oculi weakness, as documented clinically, physiologically, and microscopically, without producing systemic tetany in immunized rabbits. Tetanus toxin may have a potential application in the treatment of blepharospasm and hemifacial spasm.     

Electrical stimulation as a therapeutic option to improve eyelid function in chronic facial nerve disorders

PURPOSE: To establish whether it is possible to improve orbicularis oculi muscle function in the eyelids of patients with a chronic seventh cranial nerve palsy by using transcutaneous electrical stimulation to the point at which electrical stimulation induces a functional blink. METHODS: Ten subjects (one woman, nine men) aged 36 to 76 with chronic, moderate to severe facial nerve palsy were recruited into the study. Voluntary and spontaneous eyelid movements were assessed, using an optical measuring system, before, during, and after a 3-month treatment period. Voluntary and spontaneous lid velocities were also measured and compared with eyelid kinematic data in normal subjects (12 women, 18 men; age range, 22-56 years). RESULTS: Therapeutic electrical stimulation applied over 3 months produced improvement in eyelid movement (>2 mm) in 8 of 10 patients during voluntary eyelid closure. However, there was no significant improvement recorded in spontaneous blink amplitudes or peak downward-phase velocity of the upper eyelid. This regimen of stimulation failed to recover function well enough that a functional blink could be induced in the paretic eyelid by electrical stimulation. CONCLUSIONS: Electrical stimulation using transcutaneous electrical nerve stimulators units can improve voluntary eye closure, apparently because of a reduction in stiffness of eyelid mechanics, rather than an improvement of muscle function. Investigation of alternative stimulation regimens is warranted.     

Disorders of facial motor function

This review deals with a variety of disorders of facial movement. Recent publications on blepharospasm, facial spasm, facial myokymia, apraxia of lid opening and facial paralysis are referenced and discussed. In blepharospasm, carefully performed electromyographic studies reveal a variety of abnormal patterns of contraction of the oribicularis oculi and the levator palpebrae muscles confirming the clinical impression that blepharospasm is not a homogeneous disease. Similar studies are furthering the understanding of apraxia of lid opening, which may involve sustained contraction of the orbicularis oculi with or without failure of levator palpebrae inhibition. In both conditions botulinum toxin A injected pretarsally appears to be the preferred treatment. Of interest with respect to apraxia of lid opening is that it may be the result of a failure to sustain eye opening as well as an inability to open the eyes voluntarily. Although the fact that bilateral facial spasm was found in only five of 702 patients with spasm suggests that it is infrequent, it is also possible that bilateral facial spasm may be underdiagnosed because of lack of awareness of its existence. Despite the continued enthusiasm of neurosurgeons for microvascular decompression, the preferred treatment for facial spasm continues to be botulinum toxin A injections. It appears that a lesion of the dorsolateral pontine postgenu portion of the facial nerve is responsible for the facial myokymia of patients with multiple sclerosis. Interest in the study of lid function has increased as a result of the advent of the search coil technique for recording lid movements. Recordings with this technique have proven useful in facial nerve palsy for monitoring the degree and course of recovery and as a means of judging the effectiveness of therapy.     

Eyelid kinematics following blepharoplasty.

PURPOSE: This study characterizes the effects of blepharoplasty on blink dynamics in subjects with dermatochalasis. The authors evaluate the hypothesis that orbicularis oculi removal and the consequent alterations in blink are potentially harmful consequences of blepharoplasty. METHODS: Sixteen patients were studied, before and after laser blepharoplasty, by a modified scleral search coil technique. Changes in lid position during blinks were recorded before surgery as well as 2 months, and 1 year postoperatively. Off-line analyses assessed blink down-phase amplitude, peak velocity, duration, and main sequence (peak velocity versus amplitude) relationships. RESULTS: Despite muscle resection, there was no significant compromise of mean blink down-phase amplitude, peak velocity, or main sequence following blepharoplasty. Mean blink duration was likewise unchanged at either follow-up session from the preoperative state. Our data show that upper lid blepharoplasty does not cause any lasting decrement in lid function in blinking. CONCLUSIONS: Blepharoplasty includes resection of a portion of the orbicularis oculi. It appears unlikely that the purposeful resection of preseptal portion of the orbicularis oculi that accompanies blepharoplasty is responsible for any functional complications such as dry eye.     

Morphological study of innervation of orbicularis oculi in the cat with respect to motoneurons, nerve fibers and muscle fibers

It has been suggested that the orbicularis oculi muscle functions in different modes of action in the orbital portion and in the palpebral portion. To study the anatomical correlation between the localization of muscular division and the size of motoneurons in facial nucleus, the retrograde tracing method was used. A histochemical study on the type of muscle fibers was also performed. The relationship between the motoneurons, nerve fiber and muscle fiber was discussed in terms of the functional organization of the palpebral or orbital orbicularis oculi. We injected a tracer of 50% horseradish peroxidase (HRP) into the orbital and/or palpebral portion of the orbicularis oculi muscle and HRP-labelled motoneurons at the brainstem were studied. In the facial nucleus, four subnuclei have been described: the ventrolateral, ventromedial, dorsolateral and dorsomedial. HRP-labelled motoneurons which innervated both the orbital and palpebral portions were spindle shaped and were found ipsilaterally in the dorsolateral subnucleus, and were distributed rostrocaudally. The histogram of the average soma diameter traced by the injection in the orbital portion presented two peaks at 30 microns and 40 microns in contrast to one peak of palpebral portion. Secondly, a histochemical study using alkali (pH 10.4) preincubated ATPase and acid (pH4.3) preincubated ATPase and NADH stain was performed. It was found that the muscle fibers of the orbital part were composed predominantly of large and middle diameter group II B, while the palpebral part consisted mainly of small diameter group II A. By diameter analyses of the facial nerve fibers, it was found that the myelinated nerve fibers consisted of 3 peaks in terms of the magnitude of histogram.     

The electromyographic analysis of orbicularis oculi muscle in epiphora

Purpose:Functional epiphora is a clinical condition that presents with the complaint of watery eyes, but without anatomical stenosis in the lacrimal drainage system. Although the mechanism is not clear, there are various possibilities involving the movement of the orbicularis oculi muscle, especially its deeper segment (Horner’s muscle). We aimed to evaluate the function of the orbicularis oculi muscle in patients with patent, but dysfunctional lacrimal drainage system using a quantitative motor unit potential (MUP) analysis.Methods:Twenty-eight patients with functional epiphora (mean age = 59 years) and a control group of 28 volunteers were included in the study. Inclusion criteria were persistent and symptomatic epiphora or wiping >10 times per day and diagnosis confirmation by lacrimal irrigation test. Electromyography (EMG) was performed on the deeper segment of the orbicularis oculi muscle (medial and lateral parts). MUP parameters (duration time, amplitude, number of phases, number of turns, area, rise time, and thickness) were evaluated in both groups. Any increase in amplitude, prolongation time (>14 ms), number of turns, and satellite potential was taken as characteristic of the neurogenic type of epiphora, whereas shortened motor unit duration time, increased phase number, and low amplitude are the features of myopathic type.Results:Upon MUP analysis of the medial and lateral orbicularis oculi muscle, the increase in duration and thickness values in the medial part and the increase in duration, amplitude, area, and thickness values of the lateral part were found to be statistically significant in the patient group compared to the control group (P < 0.001). In the evaluation of the patients’ medial and lateral orbicularis oculi muscle, the increase in phase values and decrease in amplitude, area, and rise time values were found to be statistically significant (P = 0.024, P < 0.001, P < 0.001, and P = 0.010, respectively).Conclusion:These data show that functional epiphora is due to neurogenic damage of the orbicularis oculi muscle and should be investigated in more detail.     

Sustained blepharoclonus upon eye closure

A unique case of sustained, rhythmical contractions of both orbicularis oculi induced by voluntary eye closure is described. It was observed in a 25-year-old man who had suffered a severe head trauma. The lid phenomenon was synchronous with macro square-wave jerks. Sustained blepharoclonus upon eye closure is likely to be related to dysfunction in the cerebellar system.     

睑袋成形术后眼轮匝肌功能状态的临床研究

目的探讨睑袋成形术后眼轮匝肌的功能状态及其影响因素。方法用肌皮瓣法矫正下睑袋32例（64眼）,分别在术前和术后5d、14d、1个月、3个月和6个月,以结膜囊染料消失法进行泪囊排泄功能测试。结果术后5d、14d和1个月结膜囊染料消失时间较术前明显延长（P〈0．001）,3个月和6个月检测结果与术前相比差异无统计学意义（P〉0．05）。结论肌皮瓣法睑袋成形术,术后早期眼轮匝肌泵作用明显减弱;但术中精细操作,减少对组织的损伤,有利于术后眼轮匝肌泵功能的恢复。     

Orbicularis oculi muscle graft augmentation after protractor myectomy in blepharospasm

PURPOSE: To evaluate the effectiveness of free orbicularis oculi muscle grafts in correcting volume deficit deformities after protractor myectomy in patients with essential blepharospasm. METHODS: Prospective case series. During the 13-month period from October 2000 through November 2001, all patients with essential blepharospasm undergoing primary eyelid protractor myectomy received an orbicularis oculi muscle graft to replace the volume deficit deformity created by the myectomy. Only patients who had at least 6 months of postoperative follow-up were included in the analysis. RESULTS: Forty-six patients underwent primary eyelid protractor myectomy and had a free orbicularis oculi muscle graft for volume replacement. All patients had significant functional improvement of their eyelid spasms after the myectomy. Of the 38 patients who underwent upper eyelid myectomy, 3 patients were overcorrected and no patients were undercorrected with the orbicularis muscle graft. Two of the overcorrected patients underwent surgical debulking of their muscle grafts. Of the 8 patients who underwent lower eyelid myectomy, no patients were overcorrected and 1 patient was undercorrected. None of the patients were observed to have any spasms, contractions, or other signs of muscular activity or aberrant innervation of the muscle graft.CONCLUSIONS: The orbicularis oculi muscle graft is a useful adjunct to protractor myectomy in improving the aesthetic outcomes for blepharospasm patients. Our study demonstrates the viability of the orbicularis oculi muscle graft and may lead to future applications of the graft in facial aesthetics.