Objective demonstration of eyelid spasm relief with smartphone and custom software in hemifacial spasm patients.

PURPOSE: To objectively demonstrate eyelid spasms relief in hemifacial spasm (HFS) patients using a smartphone and a custom-made software. METHODS: Nineteen patients with HFS had standardized videos recorded with a smartphone (iPhone 6S, Apple) camera before and 15 days after receiving onabotulinumtoxinA injections. Nineteen age-matched control subjects were also assessed. The Eye Aspect Ratio (EAR) is an algorithm previously described to determine whether the eye is opened or closed. When the eye is closed, EAR tends to be closer to zero. Analogously, if the eye is wide open, values are greater. A custom-made software using the EAR concept was developed and pre- and post-treatment EARs were analyzed to assess HFS patients. RESULTS: Botulinum toxin (BoNT) injections led to a significant increase in the average EAR of the affected side: + 10.4% (p = 0.0175) of HFS patients, compared to baseline. Mean EAR before BoNT applications were significantly lower (16.2%) on the affected side (0.25 ± 0.05) of HFS patients when compared to controls (0.30 ± 0.05, p = 0.004). After BoNT injections, no statistically significant difference was observed for the average EAR between the affected side of HFS patients (0.27 ± 0.04) and controls (p = 0.20). CONCLUSIONS: Use of a smartphone and custom-made software objectively demonstrated eyelid spasm relief in patients with HFS. Additional refinement of this system could permit more accurate assessments of treatment response rates for each patient, making it possible to be used in clinical practice.

[Botulinum Toxin Treatment for Hemifacial Spasm:Based on the Practical Clinical Experience in the Neurology Outpatient Clinic].

Botulinum toxin(BTX)treatment is the first-line neurological treatment for hemifacial spasm(HFS). In my neurology clinic, Clinique Kita Neurologique(CKN), I have provided a cumulative total of approximately 400 BTX treatments for approximately 50 HFS patients for 23 years. Based on my own practical clinical experience, I have demonstrated the efficacy of BTX treatment. In compressive HFS, BTX treatment is indicated in patients who are not indicated or unwilling to undergo neurodecompression surgery. This is also indicated in the case of a long waiting period before surgery. In postparetic HFS, BTX treatment is indicated in patients with spasm and synkinesia. The amount of each BTX injection in postparetic HFS should be less than that in compressive HFS because of latent facial paresis. Although BTX injections can be easily administered in neurology outpatient clinics, it is important to perform the procedure safely and promptly.

Does needle size matter? Effects of micro-hypodermic needle injections of botulinum toxin type A in patients with hemifacial spasm.

INTRODUCTION: Botulinum toxin type A (BoNT/A) injections are the first-line treatment for primary hemifacial spasms (HFS), but require frequent painful injections. Although micro-hypodermic needles are commonly used for aesthetic BoNT/A injections to lessen pain and bruising, their benefits in HFS remain unclear. OBJECTIVE: To compare side effects of BoNT/A injection, specifically pain and bruising, between primary HFS patients who received injections using micro-hypodermic needles (34-G) and those using standard needles (30-G). METHODS: This cross-over, double-blind, randomised controlled trial involved HFS patients who received BoNT/A injections using either a 34-G or 30-G needle at two visits 12 weeks apart. Primary outcomes, pain and bruising were assessed immediately after injection using the Visual Analogue Scale (VAS) and Short-form McGill Pain Questionnaire (Thai version, SF-MPQ). Bruise assessment was also conducted one week after each injection. Secondary outcomes involved comparing efficacy of BoNT/A between the two types of needles and assessing other complications beyond pain and bruising. RESULTS: 65 HFS patients (47 women and 18 men; mean age 59.46 ± 11.48 years; mean disease duration 5.86 ± 4.16 years) were included in the study. Patients who received 34-G needle injections reported significantly reduced pain, as indicated by VAS, total SF-MPQ scores, and bruise scores, compared to those who received 30-G needle injections (p < 0.001, each). There were no differences in efficacy or occurrence of other complications associated with BoNT/A between the two needle types. CONCLUSION: In HFS patients, BoNT/A injections using micro-hypodermic needles resulted in reduced pain and bruising, compared to standard needles, while maintaining similar BoNT/A benefits.

How to face the hemifacial spasm: challenges and misconceptions.

Hemifacial spasm (HFS) is characterised by intermittent, brief or sustained, repetitive contractions of the muscles innervated by one facial nerve. It is one of the most frequent movement disorders affecting the face. However common and allegedly straightforward to diagnose, it might reveal as a challenge for clinicians in various situations. Indeed, it often needs prior exclusion of many other movement disorders affecting the face, with frequent phenomenological overlaps with blepharospasm, post-facial palsy, facial motor tics, etc. The clinical diagnosis shall be supported by modern brain imaging techniques, and sometimes electromyography, as some particular aetiologies may require specific treatment. Primary forms are associated with vascular compression of the ipsilateral seventh cranial nerve, whereas secondary forms can be caused by any injury occurring on the facial nerve course. This article proposes a global and organised approach to the diagnosis, and the ensuing therapeutic options, as many practitioners still use some inefficient medications when they encounter a case of facial spasm.

Profile of patients with essential blepharospasm and hemifacial spasm in the two largest ophthalmology reference centers in Brazil.

PURPOSE: Information is scarce regarding the comprehensive profile of patients with essential blepharospasm and hemifacial spasm in Brazil. The present study aimed to assess the clinical features of patients with these conditions, followed up in two reference centers in Brazil. METHODS: The study included patients with essential blepharospasm and hemifacial spasm, followed up at the Departments of Ophthalmology at Universidade Federal de São Paulo and Universidade de São Paulo. Apart from demographic and clinical features, past stressful events related to the first symptoms (triggering event), aggravating factors, sensory tricks, and other ameliorating factors for the eyelid spasms were assessed. RESULTS: A total of 102 patients were included in this study. Most patients were female (67.7%). Essential blepharospasm was the most frequent movement disorder [51/102 patients (50%)], followed by hemifacial spasm (45%) and Meige's syndrome (5%). In 63.5% of the patients, the onset of the disorder was associated with a past stressful event. Ameliorating factors were reported by 76.5% of patients; 47% of patients reported sensory tricks. In addition, 87% of the patients reported the presence of an aggravating factor for the spasms; stress (51%) was the most frequent. CONCLUSION: Our study provides information regarding the clinical features of patients treated in the two largest ophthalmology reference centers in Brazil.

Blinking Parameters Do Not Normalize After Botulinum Toxin Therapy in Blepharospasm and Hemifacial Spasm Patients.

BACKGROUND: Little is known regarding changes induced by botulinum toxin injections on blinking parameters in blepharospasm (BSP) and hemifacial spasm (HFS) patients. The purpose of this study was to investigate objective changes induced by botulinum toxin (BoNT) injections on blinking parameters in BSP and HFS patients. METHODS: Thirty-seven patients with BSP and HFS were evaluated before and 30 days after receiving onabotulinumtoxinA injections. Twelve age-matched control subjects were also assessed. Pretreatment and post-treatment parameters were assessed and compared with normal controls. A high-speed camera and microlight-emitting diodes were used to register the blinking in patients and control groups. Outcomes were blinking frequency, amplitude, and maximum velocity of eyelid closure. RESULTS: BoNT injections led to a significant reduction in all parameters, compared with baseline, in BSP and on the affected side in HFS, respectively: 22% ( P < 0.001) and 20% ( P = 0.015) in amplitude; 21% ( P = 0.04) and 39% in frequency ( P = 0.002); and 41% ( P < 0.001) and 26% ( P = 0.005) in maximum closing velocity. Blinking amplitude ( P = 0.017 and P = 0.019) and velocity ( P < 0.001 for both groups) were significantly lower at 30 days on BSP and on the affected HFS side, when compared with controls. BSP and HFS patients presented a significantly lower velocity of eyelid closure, even before BoNT, compared with controls ( P = 0.004. and P < 0.001, respectively). CONCLUSIONS: Although blinking frequency became close to normal, amplitude and velocity after BoNT applications were significantly lower in BSP and on the affected side of HFS patients when compared with age-matched normal controls, demonstrating that blinking parameters do not normalize after treatment. The velocity of eyelid closure was shown to be significantly lower, even before BoNT treatment, when compared with control subjects.

Effects of the periocular botulinum toxin on the ocular surface and anterior chamber: a prospective study in patients with hemifacial spasm and blepharospasm.

PURPOSE: To analyze using Pentacam®, the corneal and anterior chamber changes following periocular botulinum toxin injection in patients with facial dystonia. METHODS: Prospective study that included patients with facial dystonia that were going to receive a periocular botulinum toxin injection for the first time or six months or more after the previous injection. A Pentacam® examination was carried out in all patients before and 4 weeks after the injection. RESULTS: Thirty-one eyes were included. Twenty-two had a diagnosis of blepharospasm and nine of hemifacial spasm. Analysis of corneal and anterior chamber parameters revealed a significant decrease in iridocorneal angle after botulinum toxin injection (from 35 ± 10º to 33.8 ± 9.7º, p = 0.022). No other corneal or anterior chamber parameters changed significantly after the injection. CONCLUSIONS: Periocular botulinum toxin injection causes narrowing of the iridocorneal angle.

Integrative Strategy with Ayurveda and Electro-Acupuncture in Hemifacial Spasm: a Case Report.

We report a primary hemifacial spasm that started four years ago with sudden twitching of the face towards the right side. It was diagnosed as a hemifacial spasm by a neurologist and prescribed with Zeptol 100 mg 0.5 tablet BID for two weeks, followed by two sittings of Botox injection in a gap of 1 year. A year later, it reappeared more severely, driving her towards an integrative treatment modality. Ayurveda treatments including Nasya, Ksheera dhooma, internal medications, and Rasona navaneetha prayoga were administered. GV20, GB14, EX-HN5, ST3, ST4, ST6, TE17, LI4, and GB34 were selected for electro-acupuncture. The scores of hemifacial spasm grading and quality of life scale were 9 and 20 (before), 6 and 16 (after treatment), and 4 and 10 (follow-up after six months), respectively. This integrative approach was safe and has shown an improvement in hemifacial spasm.

[Quality of life in patients with hemifacial spasm after microvascular decompression and botulinum toxin therapy]. / Otsenka kachestva zhizni patsientov s gemifatsial'nym spazmom posle mikrovaskulyarnoi dekompressii i botulinoterapii.

To date, microvascular decompression (MVD) and botulinum therapy (BT) confirm own efficacy in the treatment of hemifacial spasm (HFS). Quality of life (QOL) suffers first of all in these patients. Therefore, the dynamics of QOL indicators determines postoperative outcomes. Various researchers have proposed specialized scales for assessing QoL in HPS patients (HFS-7, HFS-8, HFS-30). OBJECTIVE: To analyze QOL in patients with HPS before and after MVD and BT including HFS-7 score and regression of HFS. MATERIAL AND METHODS: We analyzed data of patients (n=80) divided into two groups: group I - MVD of the facial nerve (n=66), group II - BT (n=14). Mean age of patients was 52.4 (range 28-76) and 58.1 years (range 23-73), respectively. QOL was assessed using a questionnaire enrolling clinical and anamnestic data, as well as HFS-7 scale. Clinical severity of HFS and effect on daily activity were assessed using the Tan scale. We analyzed the results of MVD and BT considering clinical improvement (regression of spasm) and HFS-7 score. A four-level gradation of clinical regression of spasm was used. RESULTS: Patients with mild course of disease and higher QOL prefer BT. In our sample, 3 (21%) patients from the 2nd group preferred surgery a year after BT, and 13 (20%) patients from the 1st group had previously undergone BT in other hospitals. Changes in HFS-7 score before and after treatment were significant in both groups (p<0.005, t-test). Spearman's coefficient (R= -0.66) shows the correlation between clinical effect and HFS-7 score. CONCLUSION: MVD and BT significantly improve QOL in patients suffering from HFS. Patients with less severe hemispasm prefer BT, but conversion to surgery is possible as disease progresses. Both treatment methods should be available for HFS patients. Treatment outcomes should be assessed using specialized scales designed for HFS.

AChR+ Ocular Myasthenia and Facial Hemispasm: A Case Report of Unusual Association and Botulinum Toxic Type A Safety and Efficacy.

INTRODUCTION: Hemifacial spasm represents segmental myoclonus of muscles innervated by the facial nerve, which is usually and successfully treated with botulinum toxin. Botulinum toxin (BTX) acts as an acetylcholine release inhibitor at presynaptic cholinergic junctions and therefore is considered contraindicated (or administrable with caution) in patients with neuromuscular disorders like Myasthenia Gravis (MG). Moreover, to date, the association of hemifacial spasm and ocular MG is extremely rare and only a few cases have been described. CASE PRESENTATION: We report the case of a 73 years old man with a 3-year history of ocular MG who developed a left hemifacial spasm. The patient underwent hemispasm, treatment with BTX type A (abobotulinum toxin-A, total dose of 50 IU) that resulted in safe and successful 6 months re-evaluation. CONCLUSION: Our results suggest that in selected cases with concomitant MG and conditions characterized by orbicularis oculi spasms or hemispasm, BTX therapy may not be contraindicated and could be given at longer intervals due to prolonged effects.

Frequency of Hemorrhagic Side Effects of Botulinum Neurotoxin Treatment in Patients with Blepharospasm and Hemifacial Spasm on Antithrombotic Medication.

The aim of this study was to investigate the frequency of hemorrhagic side effects of botulinum neurotoxin A injections (BoNT/A) for the treatment of benign essential blepharospasm (BEB) and hemifacial spasm (HFS) in patients taking antithrombotic drugs (ATD). A total of 140 patients were included (female: 65%; BEB: 75%; mean age: 70 ± 12 years). According to their current antithrombotic medication, participants were either assigned to the ATD group (41%), or to the control group (59%). The ATD group was further divided into subgroups depending on the medication administered: acetylsalicylic acid, ADP receptor antagonists, direct oral anticoagulants, vitamin-K antagonists, or dual antiplatelet therapy. The frequency of hemorrhagic side effects was recorded by retrospective analysis of past treatments as documented in the patient's file set in relation to the number of past treatments (hematoma frequency of past treatments, HFretro) as well as by a prospective survey capturing the side effects of one single treatment (hematoma frequency of actual treatment, HFactual). There was no significant difference in hematoma frequency between the ATD group and the control group, neither for past (HFretro: ATD: 2%; 45/2554; control: 4%; 109/2744) nor for the current BoNT/A treatments (HFactual: ATD: 30%; 16/53; control: 31%; 22/72). Even between ATD subgroups, hematoma frequency did not differ significantly. Overall, hemorrhagic side effects of the BoNT/A treatment for BEB and HFS were mild and non-disabling.

Safety and efficacy of clonazepam in patients with hemifacial spasm: A double-blind, randomized, placebo-controlled trial.

INTRODUCTION: Hemifacial spasm (HFS) is an involuntary intermittent twitching of the facial muscles. Medical and surgical treatments can be considered for HFS. Among medical treatments, clonazepam is a benzodiazepine used to treat epilepsy, psychiatric symptoms, and movement disorders. This study aimed to investigate the efficacy and safety of clonazepam for the treatment of HFS. METHODS: This randomized double-blind placebo-controlled trial prospectively enrolled patients with HFS aged 20-79 years. The patients were randomly assigned in a 1:1 ratio to receive either clonazepam (0.5 mg twice daily) or a placebo for 4 weeks. All participants underwent clinical assessment and laboratory tests at baseline and visit 2. The primary endpoint was the clinical global impression-improvement (CGI-I) score at visit 2. RESULTS: A total of 34 patients with HFS assessed for eligibility were enrolled between April 2015 and November 2016. Among them, two patients were withdrawn before randomization. Thus, the intention-to-treat analysis included 32 patients with HFS. The median CGI-I scores at visit 2 did not differ significantly between the clonazepam (3; range 1-6) and placebo (3.5; range 3-5) groups. In the safety analysis, only mild or no serious adverse events were observed. CONCLUSION: The results of this study demonstrated the safety of clonazepam in patients with HFS. However, clonazepam did not show a statistically significant effect on HFS. Further studies are needed to provide evidence of the clinical benefits in patients with HFS.

Individual Response to Botulinum Toxin Therapy in Movement Disorders: A Time Series Analysis Approach.

On a group level, satisfaction with botulinum neurotoxin (BoNT) treatment in neurological indications is high. However, it is well known that a relevant amount of patients may not respond as expected. The aim of this study is to evaluate the BoNT treatment outcome on an individual level using a statistical single-case analysis as an adjunct to traditional group statistics. The course of the daily perceived severity of symptoms across a BoNT cycle was analyzed in 20 cervical dystonia (CD) and 15 hemifacial spasm (HFS) patients. A parametric single-case autoregressive integrated moving average (ARIMA) time series analysis was used to detect individual responsiveness to BoNT treatment. Overall, both CD and HFS patients significantly responded to BoNT treatment with a gradual worsening of symptom intensities towards BoNT reinjection. However, only 8/20 CD patients (40%) and 5/15 HFS patients (33.3%) displayed the expected U-shaped curve of BoNT efficacy across a single treatment cycle. CD (but not HFS) patients who followed the expected outcome course had longer BoNT injection intervals, showed a better match to objective symptom assessments, and were characterized by a stronger certainty to control their somatic symptoms (i.e., internal medical locus of control). In addition to standard evaluation procedures, patients should be identified who do not follow the mean course-of-treatment effect. Thus, the ARIMA single-case time series analysis seems to be an appropriate addition to clinical treatment studies in order to detect individual courses of subjective symptom intensities.

Epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial / Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm

Objetivo Evaluar la presencia de epiteliopatía en limpiaparabrisas en pacientes con blefaroespasmo o espasmo hemifacial antes del tratamiento habitual con toxina botulínica y 4 semanas después. Métodos Estudio prospectivo compuesto por 31 ojos de 20 pacientes con diagnóstico neurológico de espasmo hemifacial (9 ojos de 9 pacientes) y blefaroespasmo esencial (22 ojos de 11 pacientes). Se evaluaron antes y 4 semanas después de la infiltración con toxina botulínica diversos parámetros de superficie ocular con el cuestionario OSDI, test de Schirmer, tiempo de rotura lagrimal y tinciones de fluoresceína y verde de lisamina valoradas con el test de Oxford y el grado de afectación del limpiaparabrisas palpebral. Resultados El 100% de los pacientes presentaron afectación del limpiaparabrisas palpebral antes (30% grado leve y 70% moderado) y después del tratamiento con toxina (100% grado leve). El 75% de los pacientes presentaron un OSDI normal-leve antes del tratamiento; después del tratamiento fue del 80%. El tiempo de rotura lagrimal fue de 7,2±0,2 s antes y de 7,5±0,7 s después del tratamiento. El test de Schirmer fue de 11,4±5,5 y 12,5±5,5mm antes y después del tratamiento. El test de Oxford resultó patológico inicialmente en el 69,3% de los pacientes; tras 4 semanas solo fue patológico en el 54%. Conclusión La epiteliopatía en limpiaparabrisas está presente en el 100% de los pacientes con blefaroespasmo o espasmo hemifacial. El principal mecanismo fisiopatológico que la desencadena en estos pacientes es el aumento en el coeficiente de fricción, ya que el volumen y la estabilidad lagrimal son normales (AU)

Objective To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin. Methods Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time, fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper. Results 100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The tear break-up time was 7.2±0.2 sg before and 7.5±0.7 sg after treatment. Schirmer's test was 11.4±5.5 and 12.5±5.5mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%. Conclusion Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are norma (AU)

Evaluation of MR-Tractography Findings in Hemifacial Spasm Patients Injected with Botulinum Neurotoxin.

Background and Introduction: Botulinum neurotoxin (BoNT) is a potent biological toxin extracted from Clostridium Botulinum bacteria. BoNT injection is mainly used for medical purposes; it is frequently used for cosmetic purposes as well. The hypothesis that frequent application of this treatment modality may also affect the central nervous system constitutes the subject of our study. Objective: We aimed to demonstrate the possible central effects of BoNT in hemifacial spasm patients. Methods and Materials: Diffusion tensor imaging was used for this study. Patients were divided into two groups, and the measured values for each determined bilateral neuroanatomic region were compared within the relevant group. Results: Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were found to be closer to the pathological values in the right motor cortex and in the left internal capsule areas of the patients who were injected with BoNT into the left side, in the left motor cortex area of the patients who were injected with BoNT into the right side. No significant changes were detected in other regions. Conclusion: Botulinum neurotoxin administration in patients with hemifacial spasms may cause some changes in the central nervous system as well as peripheral effects. In the case of similar studies supporting pathological changes, BoNT treatment modalities or appropriate indications may be reviewed, and regulation on excessive cosmetic use may be in question.

Therapeutic Approach to Botulinum Injections for Hemifacial Spasm, Synkinesis and Blepharospasm.

The aim of this study was to show our therapeutic outcome of botulinum injection to the facial muscles and thereby to find the best therapeutic concept which should be embraced. The decision to treat the lower eyelid with 1-point or 2-points injection was randomly taken as there is no consensus regarding this debate. Injections of the lateral end of the upper eyelid were performed more laterally to the conventional injection point, just lateral to the conjunction of the upper and lower eyelids. Twenty-three patients (12 hemifacial spasm, 6 blepharospasm, 5 post facial palsy synkinesis) were enrolled. Data were retrieved from 112 visits between 2019 and 2022. Overall, 84.9% of the treatments had moderate or marked improvement. The most common side effect was facial weakness (11.8%). Neither ptosis nor diplopia were noted. Two-points regimen in the lower eyelid was associated with a lower risk of facial weakness (p = 0.01), compared to 1-point regimen, with a better therapeutic outcome as reflected by more favorable PGI-C scores (p = 0.04). Injection of the pretarsal segment of the upper eyelid, just onto or even lateral to the conjunction of the upper and lower eyelids, lowers the risk of ptosis.

[Higher efficacy of botulinum toxin therapy for hemifacial spasm recurrence after vascular decompression. Case report and literature review]. / Uvelichenie effektivnosti botulinoterapii pri vozvrate simptomov gemifatsial'nogo spazma posle vaskulyarnoi dekompressii. Klinicheskii sluchai i obzor literatury.

Hemifacial spasm (HFS) is an involuntary synchronous tonic and/or clonic contraction of mimic muscles following ipsilateral facial nerve dysfunction. The last one is a result of neurovascular conflict between the facial nerve and vessel. Currently, vascular decompression is a pathogenetic treatment modality for primary HFS. Various authors describe postoperative recurrence of HFS, and botulinum toxin therapy remains the only option for these patients. We aimed to describe the efficacy of botulinum toxin therapy in patients with HFS recurrence after surgical vascular decompression. The article presents a female patient with a long-term history of HFS and botulinum toxin therapy (with different formulations). Efficacy of therapy gradually decreased (progressive reduction of intervals between injections). MRI revealed a close relationship between posterior inferior cerebellar artery and roots of acoustic-facial nerves near the brainstem. The patient underwent vascular decompression of the left facial nerve root under intraoperative monitoring with positive postoperative outcome. However, HFS symptoms recurred in 3 days after surgery. Botulinum toxin type A (BTA) injections were resumed with significant positive effect that can be explained by reduction of one of the factors involved into HFS. Thus, patients with HFS recurrence after vascular decompression may benefit from BTA therapy.

A Double-Blind, Placebo-Controlled Study of Appropriate Site of Botulinum Toxin Therapy in Hemifacial Spasm.

INTRODUCTION: Hemifacial spasm (HFS) is a condition causing poor quality of life. Treatment with botulinum toxin A (BTX) injection is effective. Only one randomized controlled trial with a single-blind fashion has evaluated if oral injection is needed in HFS. The present study aimed to evaluate the necessity of oral BTX injection in HFS by a randomized, double-blind, placebo-controlled method. METHODS: We conducted a double-blind, placebo-controlled trial in patients with HFS who never received BTX treatment. Eligible patients randomly received either 15 units of BTX around the eye and normal saline around the mouth (group A) or 15 units of BTX around both the eye and the mouth (group B). The primary outcomes were self-reported symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the injection and the recurrence of symptoms to the same condition as before treatment. Student t test and survival analyses were used to compare the duration of symptoms between both groups. The mean changes were compared to secondary outcomes between the two groups. RESULTS: There were 60 patients enrolled, half in each group. Baseline characteristics between both groups were similar. The mean (SD) of the duration of improvement in group A and B was 22.97 (18.85) and 17.53 (14.90) weeks, respectively (p = 0.220). There was no difference between both groups by survival analysis. Group B had a higher percentage of mouth improvement but there was no difference in the percentage of eye improvement, visual analog scale of eye and mouth spasm, or frequency of eye and mouth spasm. Group B had a higher incidence of side effects particularly mouth drooping (30% vs 10%) than group A (p = 0.053). CONCLUSION: The mouth injection of BTX may not be necessary for HFS. It may be beneficial to reduce mouth symptoms with a higher rate of mouth drooping.

Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm.

OBJECTIVE: To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin. METHODS: Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time (BUT), fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper. RESULTS: 100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The BUT was 7.2 ±â€¯0.2 sg before and 7.5 ±â€¯0.7 sg after treatment. Schirmer's test was 11.4 ±â€¯5.5 and 12.5 ±â€¯5.5 mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%. CONCLUSION: Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are normal.

Tear meniscus, corneal topographic and aberrometric changes after botulinum toxin-a injection in patients with blepharospasm and hemifacial spasm.

PURPOSE: To investigate the effect of botulinum neurotoxin-A (BTX-A) treatment on dry eye symptoms, tear meniscus, corneal topography and corneal aberrometry in patients with benign essential blepharospasm (BEB) and hemifacial spasm (HFS). MATERIALS AND METHODS: This prospective study comprised of 6 patients with BEB and 20 patients with HFS. Tear meniscus height (TMH) and depth (TMD), tear break-up time (TBUT), corneal fluorescein staining score (CFSS), Schirmer I test, ocular surface disease index (OSDI) score, corneal topography [corneal power of flat axis (K1), corneal power of steep axis (K2), mean corneal power (Km), astigmatism and thinnest pachymetry] and anterior corneal aberrometry [spherical aberration (SA), vertical coma (vcoma), horizontal coma (hcoma), higher order root mean square (hRMS) and total RMS] were evaluated before BTX-A treatment, 3 weeks after BTX-A treatment and 2 months after BTX-A treatment. RESULTS: Six patients with BEB and 20 patients with HFS treated with BTX-A were evaluated in this study. Twenty contralateral spasm free eyes of 20 HFS patients were taken as control group. TMH and TMD were found to be significantly higher in eyes with spasm at both 3 weeks and 2 months after injection (TMH: 279.0 ± 123.2 at pretreatment, 380.5 ± 174.7 at third week and 317.0 ± 125.5 at second month p < 0.001 and p = 0.02, respectively), (TMD: 183.7 ± 59.7 at pretreatment, 235.7 ± 91.1 at third week and 209.8 ± 77.1 at second month p < 0.01 and p = 0.015, respectively). TBUT, CFSS, Schirmer I test values were similar (p > 0.05). OSDI scores decreased significantly from 29.6 ± 25.3 to 19.8 ± 20. p = 0.03 at third week and increased again by second month. K2 (43.9 ± 1.7 vs. 43.7 ± 1.6, p = 0.03) and astigmatism (0.8 ± 0.5 vs. 0.6 ± 0.4, p = 0.04) values were significantly lower at third week and increased again by second month. Pachymetry and aberrometric values did not change significantly. In the control group only Schirmer I test value decreased significantly at second month (10.5 ± 6.5 vs. 7.2 ± 5.6, p = 0.008), other parameters did not change. CONCLUSION: BTX-A injection increases tear meniscus and decrease symptoms related to dry eye disease in BEB and HFS patients. It decrease astigmatism and keratometry values, it does not cause a significant change in corneal aberrations. However the positive effects of BTX-A injection on ocular surface is temporary.