Le blépharospasme post paralytique. À propos de 04 cas et revue de la littérature

Malgré sa bénignité, le blépharospasme post paralytique reste une affection pénible pour le patient du fait de ses répercussions multiples: fonctionnelles,psychologiques et sociales nécessitant ainsi une prise en charge multidisciplinaire. La méconnaissance des éléments de cette pathologie par les praticiens peut faire courir au patient des désagréments certains à cause de l'errance diagnostique et la prise en charge incomplète voire même inadéquate.L'idée mobilisatrice de ce travail est notre expériencesur le blépharospasme post paralytique dans le service de neurochirurgie du CHU de BAJAIA (Algérie) lorsque nous avons commencé à traiter chirurgicalement la paralysie faciale périphérique définitive par anastomose hypoglosso-faciale latéro-terminale en 2016. Nous avons opéré à ce jour 34 patients sur une cohorte de 150 patients qui ont présenté une paraly sie faciale périphérique toute étiologie confondue. Ce sont les patients non opérés car ayant déjà récupéré de leur paralysie, qui présentent au cours de la réha-bilitation de la fonction de leur nerf facial, un défaut derégénérescence occasionnant une dystonie faciale dont le Blépharospasme est l'une des manifestations les plus gênantes

Sensory Trick Frames: A New Device for Blepharospasm Patients

OBJECTIVE: To determine whether the use of unique customized spectacles provided with modified side arms may be helpful in reducing benign essential blepharospasm (BEB) in patients describing periocular sensory tricks (ST). METHODS: A prospective descriptive study of patients with BEB with positive periocular or temporal region ST phenomenon response under the care of the Botox Clinic at Moorfields Eye Hospital, London, UK. Nine consecutive patients with BEB describing ST were recruited, and the disease frequency and severity were assessed with the Jankovic Rating Scale (JRS) and the Blepharospasm Disability Index (BSDI) before and after the use of the sensory trick frames (STF). RESULTS: A reduction in the score was noted in both severity (p = 0.0115) and frequency patterns (p = 0.0117) in the JRS in patients using the STF. A significant reduction of the BSDI score was also observed (p = 0.0314). CONCLUSION: All the patients selected and fitted with the STF had a reduction in spasms and related symptoms. This new device may be helpful in some selected BEB patients who previously responded positively to periocular pressure alleviating maneuvers.

Comparison of Safety and Efficacy of Botox and Neuronox in the Management of Benign Essential Blepharospasm: A Split-face Study

PURPOSE: To compare the efficacy and safety of Botox and Neuronox in the management of benign essential blepharospasm (BEB). METHODS: We performed a triple-masked, randomized control study to compare Botox and Neuronox in 48 eyes of 24 patients with BEB. All 24 patients randomly received Botox or Neuronox in the periorbital region in a masked, randomized split-face manner, keeping the injection sites and doses uniform. The toxin preparation, injection, and clinical evaluations were done by three independent observers. Objective outcome measures included improvement in the severity of spasm, grading of the functional visual status, changes in palpebral fissure height, lagophthalmos, superficial punctate keratitis and Schirmer's test at 2 weeks, 6 weeks, and upon conclusion of the effect of the toxin. Subjective outcome measures included duration of the effect and a forced choice stating which half of the face was better. Evaluations were performed through clinical measurements, external digital photography, and high-definition videography. RESULTS: The mean duration of relief from spasms was 3.78 months (standard deviation, 1.58 months; range, 1 to 6 months). The improvement in the objective parameters like severity of spasm and functional visual status was statistically significant at the 2-week and 6-week follow-up visits (p < 0.001). The changes in palpebral fissure height, lagophthalmos, and superficial punctate keratitis were equally observed in both groups. At 2 and 6 weeks, three of 24 (12.5%) and one of 24 (4%) patients, respectively, reported an unequal effect between the two sides of the face, but this difference was not statistically significant. At final follow-up (conclusion of the toxin effect), patients reported equal effect with no preference for either hemiface. No statistically significant differences were found in the comparative analysis between the Neuronox and Botox groups. CONCLUSIONS: Neuronox and Botox are comparable in terms of their safety and efficacy in the management of BEB.

Epidemiological and clinical aspects of a sample of Brazilian patients with primary dystonia and the impact of the new classification on their clinical evaluation / Aspectos epidemiológicos e clínicos de uma amostra de pacientes brasileiros com distonia primária e impacto da nova classificação em sua avaliação clínica

ABSTRACT Dystonia is a relatively common movement disorder but some of its epidemiological and clinical aspects have not been well characterized in Brazilian patients. Also, a new clinical classification for the disorder has been proposed and its impact on clinical practice is unclear. We aimed to describe the clinical and demographic characteristics of a Brazilian series of patients with primary dystonia, to estimate its local prevalence, and to explore the impact of using a new classification for dystonia. We identified 289 patients with primary dystonia over a 12-month period, of whom235 underwent a detailed evaluation. Patients with primary dystoniamade up one-sixth of all patients evaluated at the service where the study was conducted, with an estimated local prevalence of 19.8/100,000 inhabitants. The clinical and demographic characteristics of the patients were similar to those described elsewhere, with blepharospasm as the most common focal dystonia and most patients using sensory tricks that they judged useful on a day-to-day basis. The application of the new classification was easy and simple, and the systematic approach allowed for a better clinical characterization of our patients. We recognized two dystonic syndromes that were not described in the original article that proposed the classification, and suspected that the arbitrary distinction between generalized and multifocal dystonia seems not to be useful for patients with primary dystonia. In conclusion, the prevalence and clinical characteristics of our patients were not distinct from other studies and the new classification was shown to be practical and useful to characterize patients with dystonia.

RESUMO A distonia é um distúrbio de movimento relativamente comum e alguns de seus aspectos epidemiológicos e clínicos ainda não foram bem caracterizados em pacientes brasileiros. Além disso, uma nova classificação clínica para o transtorno foi proposta e seu impacto na prática clínica não é claro. Nosso objetivo é descrever as características clínicas e demográficas de uma série brasileira de pacientes com distonia primária, estimar sua prevalência local e explorar o impacto do uso de uma nova classificação para distonia. Foram identificados 289 pacientes com distonia primária (PDYS) durante um período de 12 meses, dos quais 235 foram submetidos a uma avaliação detalhada. Os pacientes com PDYS corresponderam a um sexto de todos os pacientes avaliados no serviço em que o estudo foi realizado, com uma prevalência local estimada de 19,8/100.000 habitantes. As características clínicas e demográficas dos pacientes foram semelhantes àquelas descritas em outros locais, com o blefaroespasmo como distonia focal mais comum e a maioria dos pacientes apresentando truques sensoriais que julgaram úteis no dia-a-dia. A aplicação da nova classificação foi fácil e simples, e a abordagem sistemática permitiu uma melhor caracterização clínica de nossos pacientes. Reconhecemos duas síndromes distônicas que não foram descritas no artigo original que propôs a classificação e suspeitamos que a distinção arbitrária entre distonia generalizada e multifocal parece não ser útil para pacientes com PDYS. Em conclusão, a prevalência e as características clínicas de nossos pacientes não foram distintas de outras amostras e a nova classificação mostrou-se prática e útil para caracterizar pacientes com distonia.

Blepharospasm with elevated anti-acetylcholine receptor antibody titer / Blefaroespasmo com título elevado de anticorpos antirreceptores de acetilcolina

ABSTRACT Objective: To determine whether serum levels of anti-acetylcholine receptor antibody (anti-AChR-Abs) are related to clinical parameters of blepharospasm (BSP). Methods: Eighty-three adults with BSP, 60 outpatients with hemifacial spasm (HFS) and 58 controls were recruited. Personal history, demographic factors, response to botulinum toxin type A (BoNT-A) and other neurological conditions were recorded. Anti-AChR-Abs levels were quantified using an enzyme-linked immunosorbent assay. Results: The anti-AChR Abs levels were 0.237 ± 0.022 optical density units in the BSP group, which was significantly different from the HFS group (0.160 ± 0.064) and control group (0.126 ± 0.038). The anti-AChR Abs level was correlated with age and the duration of response to the BoNT-A injection. Conclusion: Patients with BSP had an elevated anti-AChR Abs titer, which suggests that dysimmunity plays a role in the onset of BSP. An increased anti-AChR Abs titer may be a predictor for poor response to BoNT-A in BSP.

RESUMO Objetivo: Determinar se os níveis séricos do anticorpo antirreceptor de acetilcolina (anti-AChR-Abs) estão relacionados aos parâmetros clínicos do blefaroespasmo (BSP). Métodos: Fora recrutados 83 adultos com BSP, 60 pacientes ambulatoriais com espasmo hemifacial (HFS) e 58 controles. Foi aplicado um questionário para registrar história pessoal, fatores demográficos, resposta à toxina botulínica tipo A (BoNT-A) e outras condições neurológicas. Os níveis de anti-AChR-Abs foram quantificados usando um ensaio imunoenzimático. Resultados: O nível de anti-AChR-Abs foi de 0,237 ± 0,022 unidades de densidade óptica (OD) no grupo BSP, significativamente diferente em comparação com o grupo HFS (0,160 ± 0,064) e o grupo controle (0,126 ± 0,038). O nível de anti-AChR-Abs se correlacionou com a idade e a duração da resposta à injeção de BoNT-A. Conclusão: Pacientes com BSP apresentaram títulos elevados de anti-AChR-Abs, o que sugere que a desimunidade desempenha um papel no surgimento de BSP. O aumento do título de anti-AChR-Abs pode ser um preditor de resposta insuficiente à BoNT-A em BSP.

Clinical Features of Benign Essential Blepharospasm in Korean Patients

PURPOSE: To analyze the clinical features of benign essential blepharospasm in Korean patients. METHODS: Patients diagnosed with benign essential blepharospasm in Kim's Eye Hospital from November 2014 to December 2016 were evaluated using a clinical examination and questionnaire. The questionnaire reviewed personal medical history, demographic factors, risk factors for blepharospasm development, and relieving and aggravating factors. RESULTS: Of the 101 patients enrolled, 78 (77.2%) were women. The mean age was 64.9 years old. Hypertension was the most common medical disorder (42.6%), followed by diabetes mellitus. The majority of the patients were non-smokers (83.2%) and drank less than a cup of a caffeinated beverage a day (30.7%). Fifty-seven percent of patients reported no stressful events immediately prior to symptom development. Fatigue and stress were aggravating factors in more than 55% of patients; rest was the most common relieving factor (35.6%). CONCLUSIONS: Here, we report the clinical features of benign essential blepharospasm in Korean patients for the first time. The results were consistent with previous reports showing that the majority of benign essential blepharospasm patients are women and non-smokers. In contrast to previous reports though, fatigue and stress were aggravating factors, and the most common relieving factor was rest. No stressful events had immediately preceded the development of blepharospasm in 57.4% of patients. This report may aid in treating and counseling patients with benign essential blepharospasm.

Long-term Efficacy of Botulinum Neurotoxin-A Treatment for Essential Blepharospasm

PURPOSE: In the present study, we investigated the treatment efficacy and clinical outcomes of botulinum neurotoxin-A (BoNT-A) administered for longer than 5 years to patients with essential blepharospasm. METHODS: We retrospectively reviewed 19 patients (male : female = 8 : 11) diagnosed with essential blepharospasm between March 2006 and July 2016 who underwent BoNT-A injections for over 5 years and were followed. Efficacy of 297 injections of Botox (n = 162), Meditoxin (n = 75), Hugel-tox (n = 40), or Dysport (n = 20) was based on the symptom improvement score at the final injection (−1, worse; 0, same; 1, better). Injection dose (botox unit), duration of efficacy (months), and adverse events were also investigated. RESULTS: Based on product type, significant differences in patient age (59.3 ± 9.8 years), disease period (5.0 ± 5.4 years), number of botulinum neurotoxin injections before visiting our clinic (1.6 ± 2.6), and follow-up period (7.2 ± 1.6 years) were not observed. Treatment efficacy score and injection dose of repetitive injections were 0.1 ± 0.5 and 39.1 ± 4.0 units, respectively, and did not show significant differences with repeated injections. Duration of response was 5.9 ± 5.4 months, but this significantly decreased as the injections were repeated (p < 0.01). Among the 297 injections, adverse events occurred 12 times (4.0%) with no severe sequelae. CONCLUSIONS: In this study, we showed that repetitive, long-term BoNT-A injections are considered a stable and effective treatment for essential blepharospasm in terms of consistent injection dose and maintenance of treatment efficacy. However, the duration of long-term efficacy could be decreased in patients injected repetitively.

Uso de la toxina botulínica en pacientes con alteraciones espásticas palpebrales / Use of botulinum toxin in patients with palpebral spastic alterations

Objetivo: evaluar los resultados terapéuticos de la aplicación de toxina botulínica A en pacientes con alteraciones espásticas palpebrales. Métodos: se realizó un estudio observacional, descriptivo, longitudinal y prospectivo en 18 pacientes con estas afecciones, seleccionados en la consulta de Oculoplastia del Instituto Cubano de Oftalmología Ramón Pando Ferrer en el período comprendido entre enero y diciembre del año 2016. Se describió la muestra según la edad, el sexo, el color de la piel, los antecedentes patológicos personales, las afecciones palpebrales y las limitaciones en tareas de la vida diaria. Se evaluó en el posoperatorio el tiempo de desaparición de los síntomas, la duración del efecto de la inyección de toxina botulínica, las complicaciones inmediatas y las mediatas. Resultados: el 70,6 por ciento estuvo comprendido en el rango de edad mayor de 60 años, y el 52,9 por ciento fueron mujeres. La piel blanca constituyó el 58,8 por ciento de la muestra. La afección que se presentó con mayor frecuencia fue el blefaroespasmo (47,1 por ciento). Todos los pacientes presentaron limitaciones para realizar tareas de la vida diaria. El 100 por ciento presentó dolor en el sitio de la inyección. En el 94,1 por ciento de ellos hubo desaparición de los movimientos involuntarios entre el cuarto y el quinto día posterior a la aplicación de xeomeen y en el 88,2 por ciento demoró la reaparición de los síntomas entre cuatro y seis meses. Conclusiones: la toxina botulínica es efectiva en la corrección de las afecciones palpebrales espásticas con desaparición de los síntomas en un período de tiempo entre cuatro y cinco días, con una rápida incorporación del paciente a la vida laboral y social por cuatro a seis meses(AU)

Objective: to evaluate the therapeutic results of the application of toxin botulínica A in patients with palpebral spastic alterations. Methods: an observational, descriptive, longitudinal and prospective study was performed on 18 patients with these conditions, who were selected at the Oculoplasty Service of Ramón Pando Ferrer Cuban Institute of Ophthalmology in the period from January to December 2016. The analyzed variables were age, sex, race, personal pathological history, eyelid disorders and restricted daily life. In the postoperative period, length of time for symptom relief, duration of the effect of botulinum toxin injection, and immediate and mediate complications were assessed. Results: in the group, 70,6 percent were included in the over 60 y age group and 52,9 percent were women. Caucasians accounted for 58,8 percent of the sample. The most frequent condition was blepharospasm (47,1 percent). All patients had limitations to perform daily life tasks. In 94,1 percent of the patients, involuntary movements disappeared between the 4th and the 5th day after the administration of Xeomeen and in 88,2 percent, the symptoms delayed to appear again from 4 to 6 months. Conclusions: botulinum toxin A is an effective alternative to correct palpebral spastic conditions, with symptoms disappearing in four to five days, and quick reincorporation of the patient to working and social life for 4 to 6 months(AU)

Sonographic Alteration of Basal Ganglia in Different Forms of Primary Focal Dystonia: A Cross-sectional Study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Few studies have addressed whether abnormalities in the lenticular nucleus (LN) are characteristic transcranial sonography (TCS) echo features in patients with primary dystonia. This study aimed to explore alterations in the basal ganglia in different forms of primary focal dystonia.</p><p><b>METHODS</b>cross-sectional observational study was performed between December 2013 and December 2014 in 80 patients with different forms of primary focal dystonia and 55 neurologically normal control subjects. TCS was performed in patients and control subjects. Multiple comparisons of multiple rates were used to compare LN hyperechogenicity ratios between control and patient groups.</p><p><b>RESULTS</b>Thirteen individuals were excluded due to poor temporal bone windows, and two subjects were excluded due to disagreement in evaluation by sonologists. Totally, 70 patients (cervical dystonia, n = 30; blepharospasm, n = 30; oromandibular dystonia, n = 10) and 50 normal controls were included in the final analysis. LN hyperechogenicity was observed in 51% (36/70) of patients with primary focal dystonia, compared with 12% (6/50) of controls (P < 0.001). Substantia nigra hyperechogenicity did not differ between the two groups. LN hyperechogenicity was observed in 73% (22/30) of patients with cervical dystonia, a greater prevalence than in patients with blepharospasm (33%, 10/30, P = 0.002) and oromandibular dystonia (40%, 4/10, P = 0.126). LN hyperechogenicity was more frequently observed in patients with cervical dystonia compared with controls (73% vs. 12%, P < 0.001); however, no significant difference was detected in patients with blepharospasm (33% vs. 12%, P = 0.021) or oromandibular dystonia (40% vs. 12%, P = 0.088).</p><p><b>CONCLUSIONS</b>LN hyperechogenicity is more frequently observed in patients with primary focal dystonia than in controls. It does not appear to be a characteristic TCS echo feature in patients with blepharospasm or oromandibular dystonia.</p>

Progressive Supranuclear Palsy-Like Syndrome after Surgical Repair of Chronic Ascending Aorta Dissection

A 70-year-old woman underwent cardiopulmonary bypass surgery for aorta dissection. After 10 days she developed a vertical gaze palsy, and 2 months later she presented with dysarthria, bradykinesia, postural instability, blepharospasm, and truncal tilt to the left. Brain imaging indicated old lacunes in the bilateral thalamus. Her symptoms remained unchanged during a 4-year follow-up, which seems to be incompatible with progressive supranuclear palsy (PSP). However, the clinical features of this case were suggestive of PSP-like syndrome after cardiopulmonary bypass surgery.

Movement Disorders Following Cerebrovascular Lesion in the Basal Ganglia Circuit

Movement disorders are primarily associated with the basal ganglia and the thalamus; therefore, movement disorders are more frequently manifest after stroke compared with neurological injuries associated with other structures of the brain. Overall clinical features, such as types of movement disorder, the time of onset and prognosis, are similar with movement disorders after stroke in other structures. Dystonia and chorea are commonly occurring post-stroke movement disorders in basal ganglia circuit, and these disorders rarely present with tremor. Rarer movement disorders, including tic, restless leg syndrome, and blepharospasm, can also develop following a stroke. Although the precise mechanisms underlying the pathogenesis of these conditions have not been fully characterized, disruptions in the crosstalk between the inhibitory and excitatory circuits resulting from vascular insult are proposed to be the underlying cause. The GABA (gamma-aminobutyric acid)ergic and dopaminergic systems play key roles in post-stroke movement disorders. This review summarizes movement disorders induced by basal ganglia and thalamic stroke according to the anatomical regions in which they manifest.

Comparative Study of Hugel-tox(R) versus Botox(R) for the Treatment of Essential Blepharospasm

PURPOSE: To compare clinical efficacy and duration of Hugel-tox(R) (also known as Botulax(R)) and Botox(R) for the treatment of essential blepharospasm. METHODS: A total of 48 patients who were injected with Hugel-tox(R) (17 females, 7 males) or Botox(R) (18 females, 6 males) from February 2013 to October 2013 were enrolled in the present study. Changes in eyelid closing force and Scott grade before and after injection were analyzed. Adverse events were also evaluated. RESULTS: There were no significant differences between the Hugel-tox(R) and Botox(R) groups in clinical efficacy and duration. Before and after injection, changes in Scott grade (Hugel-tox(R): -1.17 +/- 0.70, Botox(R): -1.21 +/- 0.72, p = 0.840), changes in eyelid closing force (Hugel-tox(R): -1.38 +/- 0.58, Botox(R): -1.17 +/- 0.56, p = 0.212) and duration (Hugel-tox(R): 116.08 +/- 22.12 days, Botox(R): 126.92 +/- 38.94 days, p = 0.242) were shown. No serious adverse events were found in either group. CONCLUSIONS: Hugel-tox(R) showed nearly equal efficacy and duration compared with Botox(R).

Clinical Outcomes of Individualized Botulinum Neurotoxin Type A Injection Techniques in Patients with Essential Blepharospasm

PURPOSE: To assess the clinical outcomes following botulinum neurotoxin type A (BoNT-A) treatment with an individualized injection technique based on the types of spasms and to compare the results of the individualized injection technique with those of the conventional injection technique in the same patients. METHODS: From November 2011 to July 2013, 77 BoNT-A injections were performed in 38 patients. Eighteen patients were treated with conventional BoNT-A injections before 2011, and 20 patients were referred to our hospital for unsatisfactory results after a conventional injection technique. We classified the patients by spasm-dominant sites: the lateral orbital area, representing the orbital orbicularis-dominant group (ODG); the glabella, representing the corrugator-dominant group (CDG); and the ptosis, representing the palpebral part of the orbicularis-dominant group (PDG). We increased the injection dose into the spasm-dominant sites of the blepharospasm groups. We assessed subjective symptom scores (functional disability score, FDS) after treatment. RESULTS: This study included 38 patients (26 women, 12 men; mean age, 60.6 +/- 10.9 years). There were 21 patients in the ODG, 10 patients in the CDG, and 7 patients in the PDG. Mean ages were 59.7 +/- 12.6, 59.8 +/- 8.5, and 66.8 +/- 9.0 years, and mean BoNT-A injection dose was 38.8 +/- 11.2, 38.8 +/- 11.2, and 38.8 +/- 10.8 U in each group, respectively (p = 0.44, 0.82 Kruskal-Wallis test). Mean FDS after injection was 1.7 +/- 0.7 in the ODG, 1.4 +/- 0.8 in the CDG, and 1.2 +/- 0.3 in the PDG. There were significant differences in reading and job scale among the three groups. In a comparison between the conventional and individualized injection techniques, there was a significant improvement in mean FDS and in the reading scale in the PDG with the individualized injection technique. The success rate was 92.1% in the conventional injection group and 94.1% in the individualized injection group. CONCLUSIONS: The individualized injection technique of BoNT-A according to the spasm-dominant site is an effective and safe treatment method for essential blepharospasm patients.

Efficacy observation of acupuncture method of tonifying-qi and dredging-meridian for blepharospasm / 中国针灸

<p><b>OBJECTIVE</b>To compare differences of therapeutic effect between acupuncture method of tonifying-qi and dredging-meridian and conventional acupuncture method.</p><p><b>METHODS</b>Seventy cases of blepharospasm were randomly divided into an observation group and a control group, 35 cases in each one. Cuanzhu (BL 2), Yuwei (Extra) through Yuyao (EX-HN 4), Xinming 1 (Extra), Sibai (ST 2) and Yintang (GV 29) were selected as main acupoints. The acupuncture method of tonifying-qi and dredging-meridian was applied in the observation group, which was an acupuncture manipulation that could achieve strong needling sensation of qi arrival combined with electric-impulse stimulation. The conventional acupuncture method was applied in the control group. The treatment was given once every other day, 10 times as a session for continuous three sessions in both groups. The severity of blepharospasm was compared before and after treatment in two groups and clinical therapeutic effect was assessed. Follow-up visit was performed after half a year to observe the recurrence rate.</p><p><b>RESULTS</b>The cured and markedly effective rate was 77.1% (27/35) in the observation group, which was superior to 51.4% (18/35) in the control group (P < 0.05). Among cured and markedly effective patients in both groups, the recurrence rate was 20.0% (4/20) in the observation group, which was inferior to 54.5% (6/11) in the control group (P < 0.05) in the follow-up visit.</p><p><b>CONCLUSION</b>The acupuncture method of tonifying-qi and dredging-meridian could effectively improve severity of blepharospasm, which has superior short-term and long-term effects to conventional acupuncture method.</p>

The Difference in Filaments between Corneal Occlusion and Keratoconjunctivitis Sicca

PURPOSE: To examine histopathological findings of filamentary keratitis due to corneal occlusion. METHODS: We analyzed filamentary keratitis in 11 eyes with corneal occlusion due to blepharospasm, ptosis and paralytic strabismus, 11 eyes with keratoconjunctivitis sicca, and 13 eyes with both corneal occlusion and keratoconjunctivitis sicca. The following protocols were used for filament analyses: slit lamp examination for counting filament numbers, impression cytology for grading mucin content, and histopathology (hematoxylin and eosin staining) and immunohistochemistry (with AE1/AE3, MUC1, 5AC, 16) for histological analysis. RESULTS: Slit lamp biomicrosopy showed a significantly smaller number of filaments in the corneal occlusion group (11 eyes, 2.7 +/- 1.4) than the keratoconjunctivitis sicca group (11 eyes, 5.1 +/- 2.2, p = 0.009). In impression cytology, the standard photograph grade of mucin content was significantly higher in the corneal occlusion group (2.7 +/- 0.9) than the keratoconjunctivitis sicca group (1.9 +/- 0.8, p = 0.034). On pathological exam, filaments showed a central filament with peripheral mucin. The central filaments were composed of core and cortex, and the core contained multiple deformed nuclei. However, the cortex was not stained by AE1/AE3, MUC1, 5AC, 16. CONCLUSIONS: Filamentary keratitis due to corneal occlusion showed a smaller number of filaments and higher mucin content than filamentary keratitis induced by keratoconjunctivitis sicca and should be considered during treatment.

effectiveness of botulinum toxin in the management of benign essential blepharospasm and hemifacial spasm

To determine the effectiveness of Botulinum toxin in the treatment of Benign Essential Blepharospasm [BEB] and Hemifacial spasm [NFS] at a tertiary care hospital. Neurology Department, Bolan Medical Complex Hospital, Quetta. 30 months from 15 March 2010 to August 2012. Quasi experimental study. All patients referred to neurophysiology laboratory for Botox [BTX] injection were enrolled in the study after taking written consent. Botox injection 1.25 units was used for BEB and 3.0 units used for HFS given in the laboratory. Patients were observed for any immediate complications and then followed at two weeks for start of improvement and side effects and then at one, three and six months for duration of lasting improvement and any side effects. In this hospital based study we enrolled 30 patients with the diagnosis of BEB and HFS. The average age of the patients was 52.47 +/- 11.59. Out of 30 patients 57% were male and 43% were female with 1.3:1 male to female ratio. Blepharospasm was observed in 53.3% patients and hemifacial spasm was observed in 46.7% patients. In 50% of patients the onset of improvement was within 4-7 days. 93.4% of patients had improvement at the end of one month and 80% patients had improvement at 3 months follow up. Total duration of benefit lasted for up to 4-5 months in 46.6% of patients, 30% patients had benefit lasting for more than 5 months. 16.7% patients noticed benefit for up to 3 months and only 6.7% patients had benefit of only 2 months. Side effects such as Ptosis, diplopia, photophobia, redness of eyes, dry eyes and facial weakness occurred in 23% of patients in first week and up to one month while only 6.7% patients continued to have side effects at 3 months. This is the first study of its kind in our local population. This study concludes that the BTX is highly effective in the management of BEB and HFS and it is well tolerated

Ocular Perforation and Visual Field Defect Caused by an Acupuncture Needle: a Case Report

PURPOSE: To report a case of globe perforation and linear retinal tear after periocular acupuncture therapy which resulted in persistent temporal field defect with normal retinal function evidenced by multifocal electroretinogram (MERG). CASE SUMMARY: A 42-year-old female presented with decreased visual acuity and pain in her right eye after a periocular acupuncture therapy for blepharospasm. At initial presentation, the best corrected visual acuity (BCVA) was 0.08 in the injured eye and the intraocular pressure was 15 mmHg. Ultrasonography showed minimal vitreous hemorrhage and fundus examination revealed a linear retinal tear in the posterior pole sparing the macula. Consequently, barrier laser photocoagulation was performed around the lesion. The patient suffered from metamorphopsia and persistent decreased visual acuity even after 3 months. On fundus examination, epiretinal membrane with macular pucker was observed on the macula. Spectral domain optical coherence tomography (SD-OCT) revealed retinal nerve fiber layer defect with a full-thickness posterior wall tear. Multifocal electroretinogram showed normal retinal function; however, Humphrey visual field test demonstrated field defect corresponding to the injury. A 25-gauge pars plana vitrectomy was performed with membranectomy and ILM peeling. One month postoperatively, improvement in BCVA and metamorphopsia was achieved; however, the scotomata remained unchanged. CONCLUSIONS: Ocular perforation or retinal tear caused by an acupuncture needle is a rare condition that has not been reported previously in Korea. Furthermore, no case of traumatic visual field defect with preserved retinal function has been reported elsewhere. Hence, the authors present a case of isolated visual field defect without retinal dysfunction following full-thickness retinal tear caused by an acupuncture needle.

The Clinical Effect of Botulinum Toxin in a Patient with Tourette's Syndrome : A Case Report and Review

Botulinum toxin, a neurotoxin, is known to be an inhibitor of cholinergic neuromuscular transmission. Recently, it was reported that the administration of botulinum toxin is effective for the treatment of focal neurological motor disorders such as cervical dystonia, blepharospasm, hemifacial spasm, spasmodic dysphonia, and writer's cramp. Several case studies reported that the botulinum toxin was administered for the treatment of motor tic or vocal tic. It was found that this toxin reduces the frequency and severity of the tic as well as the premonitory urge and symptoms. In our case study, a noticeable decrease of motor tic symptom was observed after an intramuscular injection of 300mg of botulinum toxin in an 18-year-old patient with Tourette's disorder who showed only a little improvement of motor tic and vocal tic symptoms after treatment with antipsychotic drugs for several years. This case is reported in our study and literature survey was undertaken for reviewing similar cases. In our study, an 18-year-old boy diagnosed with Tourette's disorder based on Diagnostic and Statistical Manual of Mental Disorders, fourth edition presented with the following scores : the Clinical Global Impression scale, Yale Global Tic Severity Scale (motor/vocal/severity), Premonitory Urge Score, Korean Attention-Deficit Hyperactivity Disorder Rating scale, and Kovac Depression scale which were performed prior to the treatment were 5, 21/5/50, 100, 17, and 18 points, respectively. Two weeks after the injection of botulinum toxin, the scores were 4, 17/5/40, 50, 16, and 19 points, respectively. Eight weeks after the injection of botulinum toxin, they had become 3, 15/5/30, 25, 16, and 20 points, respectively, which clearly indicates a noticeable decrease of motor tic symptom.

Cognitive Function Evaluation by Mini-Mental State Examination-Korea in Essential Blepharospasm

PURPOSE: The present study evaluated cognitive functions of Korean patients with essential blepharospasm by the Mini Mental State Examination - Korea (MMSE-K). METHODS: Atotal of 33 patients diagnosedwith essential blepharospasm were evaluated. Using the K-MMSEcognitive functions such as orientation, registration and recall, attention and calculation, language, comprehension, and decision were evaluated. RESULTS: All patients were alert and orientedwith an average K-MMSEscore of 25.2 +/- 4.0 points. The normal group scores were above 24 points in 25 patients (75%), suspected dementia scores were from 20 to 23 points in 5 patients (15%), and definite dementia scores were from 15 to 19 points in 3 patients (9%). Neurologic and brain imaging evaluation was performed in the 8 patients with suspected dementia or definite dementia. Among these patients, 2 were diagnosed with Parkinson's disease, 2 were shown to have a specific brain lesion on magnetic resonance imaging, and 1 was diagnosed with a stroke and treated with antiplatelet therapy. CONCLUSIONS: The K-MMSE can be a helpful tool for the early detection of cognitive dysfunction in outpatients with essential blepharospasm.

Avaliação da fenda palpebral após aplicação de toxina botulínica tipo A em pacientes com distonias faciais / Evaluation of palpebral fissure after botulinum toxin type A injection in patients with facial dystonias

OBJETIVO: Avaliar a medida da fenda palpebral em pacientes com blefaroespasmo essencial benigno (BEB) e espasmo hemifacial (EHF) após a aplicação periocular de toxina botulínica tipo A. MÉTODOS: Foram estudados pacientes portadores de BEB e EHF submetidos à injeção periocular de toxina botulínica tipo A pela técnica inner orbital de aplicação. Os pacientes foram fotografados em PPO antes da aplicação e catorze dias depois dela. A fenda palpebral foi mensurada nestas imagens por meio de processamento computadorizado de imagens, utilizando o programa ImageJ. As alterações da fenda palpebral foram observadas comparando-se as medidas obtidas no pré e pós-aplicação. RESULTADOS: Comparando-se as imagens obtidas com o programa ImageJ, houve aumento estatisticamente significante (p<0,001) da fenda palpebral em 14 olhos (51,8%) após a aplicação de injeção periocular da toxina botulínica e nenhuma das imagens analisadas apresentou diminuição da fenda palpebral. CONCLUSÃO: No presente estudo, os pacientes portadores de distonias faciais apresentaram aumento de fenda palpebral estatisticamente significante após aplicação periocular de toxina botulínica tipo A.

PURPOSE: To evaluate the measurement of palpebral fissure in patients with facial dystonias before and after periocular injection with botulinum toxin type A. METHODS: We studied patients with benign essential blepharospasm and hemifacial spasm underwent periocular injection of botulinum toxin type A by the inner orbital technique of application. Patients were photographed 14 days before and after application. The palpebral fissure was measured in these images by means of computerized image processing using the program ImageJ. The palpebral fissure changes were observed by comparing the measurements obtained before and after application. RESULTS: Comparing the images obtained with the program ImageJ, there was a statistically significant increase (p <0.001) of the palpebral fissure in 14 eyes (51,8%) after the application of periocular injection of botulinum toxin and the images analyzed showed no decrease of the palpebral fissure. CONCLUSION: In this study, patients with facial dystonias showed increased palpebral fissure periocular statistically significant after application of botulinum toxin type A.