Download FACIAL SPASM MANAGEMENT

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SPASMS, TWITCHES AND OTHER EYELID GLITCHES
Leonid Skorin, Jr., OD, DO, FAAO, FAOCO
I.
BENIGN ESSENTIAL BLEPHAROSPASM (BEB)
A. Definition
1. dystonia
2. involuntary sustained (tonic) & spasmodic (rapid or clonic)
repetitive contractions
3. involves: orbicularis oculi, procerus, corrugator supercilia
B. Etiology
1. lesions: thalamus, basal ganglia, cerebellum, mesencephalon
2. vascular: thalamus, basal ganglia
3. neurochemical: adrenergic variability
 decreased norepinephrine – hypothalamus, mamillary bodies,
locus ceruleus
 increased norepinephrine – dorsal raphae nucleus, red nucleus,
substantia nigra, thalamus
 genetically identifiable in 33% of patients
C. Diagnosis
1. variable episodes of increased blinking – 78%
2. dryness of eyes, grittiness, irritation, photophobia – 57%
3. ocular surface disease, eyelid pathology – 40%
4. normal muscle strength
5. aggravated by stress
6. relieved by sleep
7. age: begins 50-70, mean age of onset – 56 years
8. two-thirds are female
9. functional incapacitation – 10%
D. Differential Diagnosis – BEB
1. eyelid myokymia (benign fasiculations) – twitching that does not
cause eye blinking
2. facial myokymia – eyelid and ipsilateral facial twitching –
brainstem tumor or demyelinating disease
3. Meige’s syndrome (idiopathic orofacial dystonia) – BEB with
lower facial muscle involvement, frequently involves speechdysarthria, involuntary chewing, trismus, lip pursing, jaw
deviation, tongue protrusion
4. Breughel’s syndrome (idiopathic oromandibular dystonia) – BEB
with lower facial, mandibular and cervical muscle involvement –
contraction around the mouth, jaw, tongue, pharynx
5. segmental cranial dystonia – BEB with involvement of several
cranial nerves
6. Apraxia of lid opening (ALO) – inability to open the eyes at will,
7% of BEB patients have ALO
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7. neurodegenerative – Parkinson’s, Huntington’s chorea
8. drug induced – tardive dyskinesia, spasm secondary to
antipsychotic drugs
9. post-Bell’s palsy – aberrant regeneration and synkinesis
E. Management
1. Medical
Anti-Parkinson drugs – Sinemet (levodopa with carbidopa)
Parlodel (bromocriptine)
Norflex (orphenadrine)
Anticholinergic drugs – Artane (trihexypenidyl)
Cogentin (benztropine)
Muscle relaxants – Lioresal (baclofen)
Benzodiazepines – Valium (diazepam)
Klonopin (clonazepam)
Antidepressants – Lithobid (lithium)
Anticonvulsants – Tegretol (carbamazepine)
Depakene (valproic acid)
Tranquilizers – Haldol (haloperidol)
Beta-blockers – Inderal (propranolol)
2. Botulinum Toxin Injection
 7 different neurotoxins produced by bacteria Clostridium
botulinum
Type A – Botox (Allergan)
Type B – Myobloc (Elan)
 Inhibits release of acetylcholine at neuromuscular junction
 Botox – each vial contains 100U of botulinum toxin
-reconstituted with sterile nonpreserved 0.9% sodium chloride
-initial effect at 3 days, maximal 1-2 weeks
-3 to 6 months duration of action
-development of antibodies
 Adverse effects: lagophthalmos, decreased blinking-exposure
keratitis-40%
Ptosis-treat with Iopidine 0.5% 4xday or naphazoline
Diplopia
Ectropion, entropion
Ecchymosis, pain at injection site
3. Chemical Myectomy
 doxorubicin-antimiotic & antimetabolic
-permanent muscle fiber loss
4. Surgery
 Myectomy
 Neurectomy of facial nerve branch-30% recurrence
II.
HEMIFACIAL SPASM
A. Definition
1. dystonia
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2. involves muscles of facial expression that are innervated by the
facial nerve
3. unilateral
B. Etiology
1. microvascular compression or irritation of facial nerve by an
aberrant artery in the posterior fossa
2. cerebellopontine tumor, basilar ectasia
C. Diagnosis
3. continues during sleep
4. more common in women
5. neuroimaging required to rule-out tumor
D. Management
6. Surgery-Jannetta procedure-microvascular decompression of
facial nerve by placement of a sponge under aberrant artery-80%
cure rate
7. Botulinum toxin injection
III.
OTHER INDICATIONS FOR BOTULINUM TOXIN INJECTION
A. Ocular
 Strabismus
 Acquired nystagmus
 Lower lid entropion
 Corneal ulcer
 Corneal exposure (Bell’s palsy)
 Aberrant regeneration of 7th cranial nerve
B. Nonocular
 Spasmodic torticollis
 Spastic dysphonia
 Writer’s cramp, musician’s cramp
 Migraine headache
 Tension-type headache
C. Cosmetic
 Forehead creases
 Lateral canthal rhytides (crow’s feet)
 Perioral rhytides (lipstick lines)