外眦成形及下睑外翻缝线联合术治疗退行性下睑内翻的效果

 目的 探讨联合外眦成形、下睑外翻缝线以及睑板前轮匝肌切除术治疗退行性下睑内翻的疗效。设计 回顾性病例系列。研究对象 北京同仁眼科中心19例（23眼）退行性下睑内翻患者。方法 手术包括外眦成形矫正水平眼睑松弛,睑板前轮匝肌切除解除眼轮匝肌骑跨,下穹窿皮肤缝线折短下睑缩肌。观察术前术后患者眼睑形态、位置,有无溢泪等。随访8~12个月。主要指标 眼睑形态、位置,有无溢泪。结果 到最后随访时,所有患者下睑对称无畸形;1例患者（1眼）在睁眼时下眼睑与眼表贴附不紧密,但无明显内外翻及溢泪发生。随访期间无复发或过矫现象发生。结论 针对多种致病因素的联合外眦成形、睑板前轮匝肌切除以及下穹窿皮肤缝线术治疗退行性下睑内翻简单有效。     

Orbicularis oculi muscle extirpation in a combined procedure for involutional entropion

Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure.     

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.     

Doxorubicin chemomyectomy: injection of monkey orbicularis oculi results in selective muscle injury

Doxorubicin was injected into the preseptal portion of the orbicularis oculi of one lower eyelid in each of two cynomolgus monkeys at a dose of 2 mg. One monkey was observed for 4 days and the other for 68 days after doxorubicin injection. Although some skin ulceration was seen, it was completely healed by 3 weeks postinjection. The preseptal portion of the orbicularis oculi in both monkeys showed extensive signs of injury. At 4 days after doxorubicin injection many necrotic muscle fibers could be seen. Very few muscle fibers in the preseptal portion of the muscle remained by 68 days after injection. The pretarsal portion of the injected orbicularis oculi was relatively normal, with little evidence of injury. It appears that doxorubicin injection into the lower lid resulted in a gradient of muscle injury, with increasing severity at decreasing distances from the injection site. The extent of muscle injured is related to the dose and injection site and indicates the ability to selectively control the injury within a muscle. The ramifications of this effect on the use of doxorubicin for permanent treatment of blepharospasm and other related diseases are discussed in this first report of the injection of this drug into the eyelids of nonhuman primates.     

改良外眦韧带缩短联合眼轮匝肌缩短术治疗退行性下睑内翻的效果

目的 探讨改良外眦韧带缩短联合眼轮匝肌缩短术治疗退行性下睑内翻的效果。设计 回顾性病例系列。研究对象 北京同仁医院79例（118眼）退行性下睑内翻患者。方法 对所有患者行改良外眦韧带缩短联合眼轮匝肌缩短术,术后随访12个月,对手术效果（眼睑位置、形态、有无溢泪）及复发率进行评估。主要指标 手术效果和复发率。结果 末次随访时,117眼治愈,其中3眼术后早期出现轻度过矫,3眼中2眼眼睑位置形态于术后3个月恢复正常,另1眼于术后6个月恢复正常。1眼复发。结论 随访1年的结果显示,改良外眦韧带缩短联合眼轮匝肌缩短术治疗退行性下睑内翻效果确切,治愈率高,复发率低。     

Innervation zone of orbicularis oculi muscle and implications for botulinum A toxin therapy.

Motor points (areas of maximal sensitivity to electrical stimulation) were found in constant locations over orbicularis oculi when measured in both eyes of six normal subjects. All subjects had a motor point at the lateral terminus of the upper lid crease and the medial extent of the lower lid crease. A study of the innervation zone [distribution of neuromuscular junctions (NMJ)] was conducted on strips of pretarsal and preseptal portions of the upper eyelid orbicularis that had been removed routinely during involutional ptosis surgery. There was no significant difference in NMJ concentration between the medial and lateral sections, as determined by cholinesterase staining. Therefore, we concluded that the innervation zone is diffuse for the orbicularis muscle within this portion of the upper eyelid. Single-point injections of botulinum toxin were then compared to the conventional multiple injection sites on separate eyes in 10 patients with benign essential blepharospasm. Eight of the 10 patients reported greater relief on the side given injections into multiple points; the other two patients experienced no difference between the two methods. Both histologic data and clinical observation of response to botulinum toxin injection suggest the innervation zone for the upper orbicularis is diffuse. Thus, we conclude that multiple injections are superior to the injection of a single motor point.     

Orbicularis oculi muscle transposition for repairing involutional lower eyelid entropion

Purpose

To describe a simple technique for involutional entropion correction and to present the findings of a retrospective interventional case series study.

Methods

We studied a consecutive series of 414 patients (609 eyelids). Patients presenting with involutional entropion in the absence of lateral canthal tendon laxity underwent orbicularis oculi muscle (OOM) transposition from pretarsal position to corresponding preseptum without horizontal shortening or resection of the orbicularis muscle.

Results

Immediate resolution of entropion and associated ocular symptoms was achieved in 607 eyelids (99.67 %). An early postoperative complication was localized lid swelling that gradually subsided within one week. Over-correction occurred in six cases and resolved with pressure dressing, mostly one or two days post-operation. At final follow-up, a significant improvement in eyelid position was achieved in 579 eyelids (95.07 % ). There was mild recurrence of entropion in 30 eyelids (4.93 %). The mean follow-up was 6.84 months (range, 6–12 months).

Conclusions

Orbicularis oculi muscle transposition is a reasonably successful procedure with a high success rate, and is particularly suitable for patients for whom there exits overriding of the preseptal OOM over the pretarsal OOM.     

Microscopic anatomy of Asian lower eyelids

PURPOSE: To elucidate the microscopic anatomy of the Asian lower eyelid. METHODS: Specimens (full-thickness sections of lower eyelids from 19 postmortem lower eyelids) from 11 Asians aged 73 to 96 years at death were fixed in 10% buffered formalin and microscopically examined. After pretreatment, sagittal sliced sections of the central part were stained with Masson trichrome. RESULTS: The distinct junction of the orbital septum to the capsulopalpebral fascia (CPF) was confirmed in 7 eyelids in which orbital septum was clearly stained, with an average distance from the tarsus to the junction of 2.38 mm. The other 12 eyelids did not show a distinct junction, and the orbital septum was poorly defined anteriorly and indistinct posteriorly. There was a distinct layer between the orbicularis oculi muscle and the orbital septum. The inferior and the posterior attachments of the CPF to the tarsus were seen in all eyelids. Seventeen of the 19 eyelids had attachment of the CPF on the anterior aspect of the tarsus, from which an extension of the CPF through the pretarsal orbicularis oculi muscle was observed. All eyelids had anterior extension of the CPF through the preseptal orbicularis oculi muscle, which was overridden on the pretarsal orbicularis oculi muscle. CONCLUSIONS: The microscopic findings of Asian lower eyelids, especially fascial components, were mostly similar to those of non-Asian eyelids, but differences existed in higher or indistinct septum fusion, anterior and superior orbital fat projection, and the overriding of the preseptal orbicularis oculi muscle.     

眼轮匝肌切除联合眼轮匝肌缩短下睑缩肌复位术治疗老年性下睑内翻

目的：探究眼轮匝肌切除联合眼轮匝肌缩短下睑缩肌复位术治疗老年性下睑内翻患者疗效。

方法：回顾性分析。选取2019-06/2021-06我院收治老年性下睑内翻患者97例175眼,依据治疗方式分两组：对照组47例82眼接受眼轮匝肌切除术进行治疗,联合组50例93眼接受眼轮匝肌切除联合眼轮匝肌缩短下睑缩肌复位术进行治疗。比较两组患者近期疗效、围手术相关指标、手术前后症状与体征评分、手术前后睑裂宽度、睫毛朝向、泪阜显露率、并发症、患者满意度。

结果：术后3mo联合组患者总有效率显著高于对照组(95% vs 80%,P=0.004); 联合组患者手术出血量、手术时间以及住院时间均明显高于对照组(P<0.001); 联合组术后流泪、异物感、畏光以及刺激感症状体征评分均低于对照组(均P<0.001); 联合组患者手术后睑裂宽度、睫毛朝向、泪阜显露率均高于对照组(均P<0.001); 联合组患者术后并发症发生率低于对照组(8% vs 18%,P=0.032); 联合组患者术后舒适度、倒睫矫正、瘢痕外观、双眼对称以及外形美观患者满意度评分均高于对照组(均P<0.001)。

结论：应用眼轮匝肌切除联合眼轮匝肌缩短下睑缩肌复位术治疗老年性下睑内翻患者安全有效,可以满足患者美容要求。     

Voluntary entropion

Voluntary entropion, which has been reported only once before, was photographically documented in a 12-year-old girl. The lower-eyelid retractors and protractors were clinically normal. The postulated mechanism of the entropion was selective innervational control of separate components of the orbicularis oculi complex, which allowed the preseptal portion to override the pretarsal portion.     

Autologous Orbicularis Muscle for Filling Facial Folds—An Experimental and Clinical Study

Purpose: To present a technique for filling facial folds by using autologous orbicularis oculi muscle, based on an experimental model. Methods: two studies are presented: (1) an experimental study using 15 albino guinea-pigs from which a strip of the sural triceps muscle was removed and implanted in the subcutaneous tissue of the dorsal area. The animals were sacrificed 7, 30 and 60 days after the implantation, and the material was histologically evaluated. And (2) an interventional prospective clinical trial carried out on 20 patients referred to blepharoplasty surgery. They received autologous preseptal orbicularis muscle for filling facial folds. The results where evaluated by patients satisfaction and clinical exam. Results: the sural tricep muscle, when implanted in the subcutaneous tissue, resulted in fibrosis. The patients whom received autologous orbicularis muscle implanted for filling facial folds showed that the procedure can be successfully carried out. Conclusions: autologous preseptal orbicularis muscle is a good material for filling facial folds. Cicatricial tissue will be formed on its implantation site, filling the tissue gap that forms the folds on the skin.     

Effect of intubation in patients with functional epiphora after endoscopic dacryocystorhinostomy

AIM: To investigate the effect of bicanalicular silicone tube intubation (BSTI) in the treatment of functional epiphora after endoscopic dacryocystorhinostomy (En-DCR). METHODS: Clinical data of 84 patients (95 eyes) with functional epiphora after En-DCR were retrospectively analyzed. Functional epiphora was confirmed as persistent or recurrent epiphora by fluorescein dye disappearance test (FDDT), lacrimal irrigation test, as well as endoscopic examination. Secondary BSTIs were recommended for patients with functional epiphora. These tubes were removed 1mo after surgery. Functional success and associated complications were assessed after 2y of follow-up. RESULTS: Seven patients (9 eyes) refused intervention, 5 patients (6 eyes) did not complete postoperative follow-up, and 1 patient (1 eye) developed tube prolapse within 1mo after surgery. Seventy-one patients (79 eyes) were included at last. Functional success ratios at six months, one year, as well as two years post-operation were 94.9% (75/79), 92.4% (73/79), and 91.1% (72/79), respectively. Three eyes presented with punctal slitting (2 eyes without epiphora), 1 eye with proximal canaliculus slitting, 1 eye with canaliculus stenosis and 4 eyes with still present functional epiphora without detectable abnormal at the last follow-up. CONCLUSION: Secondary intubation is an effective procedure with low recurrence probability for functional epiphora after En-DCR. Punctal and canaliculus injury are the main tube-associated complications after secondary intubation.     

球囊管扩张术治疗儿童先天性泪道阻塞的临床观察

目的 观察球囊管扩张术治疗儿童先天性泪道阻塞的手术方法、疗效与并发症.方法 前瞻性研究.2008年5月至2009年10月,对就诊于首都医科大学附属北京儿童医院眼科的31例(50只眼)泪道探通、插管和激光术后失败的先天性鼻泪管阻塞患儿进行全身麻醉下鼻泪管球囊管扩张术,探针经泪小管探通直至鼻泪管,顺行插入尾端带有球囊的导管探针,进行鼻泪道球囊管扩张.手术前后进行症状评估、荧光染料消失试验以及泪道冲洗检查,同时对术中出血、水肿、假道形成等并发症进行观察与分析.随访时间为术后4～17个月.结果 50只眼中44只眼治愈,总成功率为88.0%(95%CI 85.5%～96.9%),荧光染料消失试验40只眼(80.0%)显示为1级或0级.主要术中并发症有10只眼(20.0%)鼻腔少量出血,有2只眼(4.0%)出现泪小点裂伤.结论 球囊管扩张术是一种便捷、安全、有效,不破坏局部解剖结构的新型儿童泪道手术方法,可用于泪道探通、插管或泪道激光手术失败后的儿童先天性泪道阻塞治疗.

Abstract：

Objective To introduce the procedure of balloon dacryocystoplasty and to evaluate its effectiveness and complications as the treatment of congenital nasolacrimal duct obstruction after a previous unsuccessful surgery. Methods Prospective case series. Balloon dacryocystoplasty was performed under general anesthesia in 50 eyes of 31 children with congenital nasolacrimal duct obstruction following previous unsuccessful surgery in Beijing Children's Hospital between May 2008 and October 2009. A probe was introduced through the punctum into the inferior meatus of the nasal cavity. A deflated balloon catheter was introduced anterogradely and the balloon was inflated several times to perform the dilation of the nasolacrimal duct. Treatment success was defined as absence of epiphora and mucous discharge,negative results of fluorescein dye disappearance test(FDDT) and the unobstructed irrigation of the lacrimal system during the follow-up period of 4 - 17 months after tube removal. Results Successful operation was reported in 44 of 50 eyes ( 88.0%;95% confidence interval 85.5% - 96. 9% ). Forty of 50 eyes were FDDT 0 - 1(80. 0% ). Major complications included epistaxis (10 eyes,20. 0% ) and lacrimal duct laceration (2 eyes,4. 0% ). Conclusion Balloon dacryocystoplasty is a safe,simple and effective procedure for congenital nasolacrimal duct obstruction following previous unsuccessful surgery without disturbing the anatomy of normal lacrimal drainage system.     

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.     

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.     

Assessing patients with epiphora who are patent to syringing: clinical predictors of response to dacryocystorhinostomy

PURPOSE: To assess the value of an abnormal fluorescein dye disappearance test (FDDT), lacrimal syringing, and Jones test for patients with epiphora who are clinically patent to syringing. METHODS: Prospective cohort study of 68 consecutive patients with epiphora who were clinically patent to syringing and otherwise normal to examination. Patients were assessed using FDDT and lacrimal syringing, as well as the Jones test comparing either single- or multiple-drop technique. FDDT and canalicular reflux on lacrimal syringing were subjectively graded. RESULTS: Success was defined as nil or only mild epiphora after surgery. Surgery was performed on 68 patients with a successful result in 64 (94%). The majority of these patients had severely delayed FDDT (90%), > or = 50% reflux on lacrimal syringing (78%), or were Jones I negative (81%). There was no significant difference between outcomes of the single- and multiple-drop tests. In patients examined with the single-drop Jones test, patients with a Jones I negative result had a statistically significant better surgical outcome (p = 0.04). This comparison was highly significant when the subgroup of patients with severely delayed/nonclearing FDDT and > or = 50% reflux was examined (p = 0.005). The results were not significant for the multiple-drop group. CONCLUSIONS: These findings show that a negative single-drop Jones I test is predictive of symptomatic improvement after dacryocystorhinostomy surgery in patients with epiphora who are clinically patent to syringing. Lacrimal syringing and the FDDT, on their own, were not predictive of surgical outcome. Jones testing was of significant value in patients, but only when the traditional single-drop test was used.     

Snip punctoplasty offers little additive benefit to lower eyelid tightening in the treatment of pure lacrimal pump failure

Lacrimal pump failure refers to epiphora due to reduced tear outflow in the presence of a patent lacrimal drainage system and well-positioned puncta. This condition has been managed with dacryocystorhinostomy and lower eyelid tightening, which carry success rates of 50-94% and 84-91%, respectively. In this retrospective study, 23 eyes with symptomatic epiphora attributed to lacrimal pump failure underwent the lateral tarsal strip procedure and lower eyelid snip punctoplasty, and 20 eyes (87%) experienced complete or nearly complete resolution of tearing. This success rate is quite similar to that of prior studies of eyelid tightening alone for lacrimal pump failure, suggesting that the addition of the snip punctoplasty may not offer any additional benefit in patients with little or no punctal stenosis. All patients displayed some degree of lower eyelid laxity on lid distraction testing preoperatively, and those with only mild lid laxity responded at least as well as those with more severe laxity.     

No histological evidence of orbicularis oculi muscle hypertrophy in congenital epiblepharon

Background: To analyse the microscopic anatomy of the orbicularis oculi muscle in patients with congenital epiblepharon and to determine whether hypertrophy of the orbicularis oculi muscle, which is considered as a possible cause of this eyelid malposition, exists. Methods: Sixty‐seven eyelids with congenital epiblepharon of 41 Japanese patients, as well as 30 control eyelids of 24 Japanese patients with other eyelid pathologies (upper eyelid: fourteen blepharoptosis, one trichiasis and two retractions; lower eyelid: five involutional entropions, one trichiasis and seven retractions) were analysed. These controls contained no orbicularis pathology such as cicatrization or orbitopathy. The muscle specimens were obtained from the central part of the pretarsal orbicularis oculi muscle during surgery. The specimens were stained with haematoxylin & eosin. Only specimens with cross‐sectional areas that included large muscle fibres were selected. In each section, 10 muscle fibres were measured across their smallest diameter, thereby avoiding inaccurate measurements of muscle kinking occurring during the processing or by any obliquity of the plane of section. Measurements of the muscle fibre diameter were made with a digital measure. Results: There were no significant differences in the average diameter of the muscle fibres between the patients with congenital epiblepharon and the control group. Conclusions: There was no evidence of orbicularis oculi muscle hypertrophy in congenital epiblepharon.     

退行性下睑内翻眼轮匝肌缩短矫正术欠矫原因及修补△

目的 分析退行性下睑内翻眼轮匝肌缩短矫正术欠矫原因,评估再次手术修补的效果。方法 收集2008~2017年我院退行性眼睑内翻行眼轮匝肌缩短矫正手术欠矫病例27例(27眼)。分析欠矫原因,并根据其原因选择相应手术方式,观察再次矫正的手术效果。结果 退行性眼睑内翻原因和修补方式为:下睑缩肌断裂未修补15例,给予下睑缩肌修复;水平松弛未矫正7例,给予外眦韧带缩短手术;5例同时存在下睑缩肌断裂和水平松弛,行下睑缩肌修复联合外眦韧带缩短手术。再次手术随访时间内[(18.74±12.11)个月]所有患者症状消失,眼睑位置正常。结论 退行性眼睑内翻眼轮匝肌缩短手术欠矫的原因为手术方式选择不完全正确,眼睑退行性改变因素未得到充分矫正。发生欠矫时,应仔细分析其原因,选择合适的手术方式,仍可以获得良好的矫正效果。     

Verapamil substantially increases the chemomyectomy effect of doxorubicin injected into rabbit or monkey eyelid.

Local doxorubicin injections have been used clinically to treat blepharospasm, hemifacial spasm, and other related disorders permanently and nonsurgically. Doxorubicin is an effective myotoxic agent for the removal of the orbicularis oculi muscle in the eyelid after local injection. Injections of this drug alone resulted in removal of up to 70% of the muscle fibers from the treated eyelids in monkeys. The authors attempted to optimize the conditions for doxorubicin myotoxicity of the orbicularis oculi. Doxorubicin was injected shortly after local verapamil injection in rabbits and a monkey in an attempt to maximize the muscle injury in the eyelid. Verapamil (dose, 0.5 mg or 1.6 mg in the rabbits), injected with a range of doses of doxorubicin, caused substantially increased muscle loss in the eyelid compared with doxorubicin alone. In the monkey, verapamil (dose, 0.25 mg) injection was followed by an injection of 1 mg of doxorubicin. Verapamil cotreatment resulted in increased muscle loss over that caused by doxorubicin alone in both rabbits and the monkey. Injection of verapamil alone also caused muscle loss, and this was quantified. The muscle loss with doxorubicin and verapamil injections included muscle in the preseptal portion of the muscle and even in the pretarsal muscle (which previously was difficult to destroy). This technique clinically might be used to decrease the dose of doxorubicin injected and/or decrease the total number of injections necessary but still retain a clinically effective treatment for blepharospasm and hemifacial spasm. The reduction in the dose of doxorubicin also may decrease the risk of skin injury from doxorubicin chemomyectomy in these patients.