Patient-reported outcomes following a break in ophthalmic botulinum toxin therapy during the COVID-19 pandemic.

OBJECTIVE: To evaluate the effect of a break in botulinum toxin treatment, necessitated by the COVID-19 pandemic, on patients' quality of life. METHODS: Prospective cohort study of all patients undergoing incobotulinumtoxinA treatment in our department-for benign essential blepharospasm (BEB), hemifacial spasm (HFS), aberrant facial regeneration (AFR), or crocodile tears-who were affected by the break in service (March 18, 2020-June 17, 2020). All patients who received treatment both before and after the break in service were included. Data gathered included subjective patient-reported measure of "time until treatment failure" and disease rating scale scores: Blepharospasm-Dystonia Functional Disability Assessment Scale (BDFDAS; for BEB, HFS, and AFR); Jankovic Rating Scale (JRS; for BEB and HFS); and TEARS Epiphora Grading Scale (for crocodile tears). RESULTS: Across 72 patients, there was a mean treatment delay of 3.9 months (range, 0-9.8 months). After a period of effect, treatment failed in all patients, with a mean time until treatment failure of 3.9 months (range, 0.5-12.0 months). All patient-reported outcome measurements increased, with greatest effect seen in AFR (178% increase in BDFDAS) and BEB (41% increase in JRS). At least 2 patients sought and underwent retreatment elsewhere in the private sector because of their symptom severity. CONCLUSIONS: Patients with AFR and BEB are likely to tolerate a break in service least, whereas patients with crocodile tears appear to be less affected. This real-world snapshot allows quantification of the harm caused by a break in botulinum toxin service or a treatment delay. This study provides valuable information should further breaks in service or treatment delay be considered in the future due to a further wave of COVID-19 or other reasons.

Switchover study of onabotulinumtoxinA to incobotulinumtoxinA for facial dystonia.

IMPORTANCE: When making a cost-saving it is important to ensure there is no loss of efficacy. BACKGROUND: Clinical effectiveness and efficiency of incobotulinumtoxinA compared to onabotulinumtoxinA in facial dystonia is unclear. Our aim is to evaluate switching from onabotulinumtoxinA to incobotulinumtoxinA in the treatment of essential blepharospasm (EB), hemifacial spasm (HFS) and aberrant facial nerve regeneration (AFR). DESIGN: A retrospective study of a prospective, single-masked switchover audit from onabotulinumtoxinA to incobotulinumtoxinA. PARTICIPANTS: Twenty essential EB, 12 HFS and six AFR patients. METHODS: A switchover from stable onabotulinumtoxinA to incobotulinumtoxinA using a 1:1 unit ratio and contemporaneous efficacy measures. Two nurse injectors performed the injections over a period of 6 years. Each masked patient received three onabotulinumtoxinA and three incobotulinumtoxinA over a minimum of 2 years. MAIN OUTCOME METHODS: At each visit, a blepharospasm disability score (BDS), Jankovic score (JS), subjective improvement (SI), duration of maximum effect (DME) and complications were recorded. A cost comparison per unit dose was made. RESULTS: Twenty EB, 12 HFS and six AFR received 114 onabotulinumtoxinA and 114 incobotulinumtoxinA treatments. Both brands had similar efficacy, but SI (P < .01) and DME (P < .05) were higher in the HFS group with incobotulinumtoxinA. Complications included bruising (two onabotulinumtoxinA, one incobotulinumtoxinA) and ptosis (three onabotulinumtoxinA, zero incobotulinumtoxinA). OnabotulinumtoxinA was 33% pricier. CONCLUSION AND RELEVANCE: Switching from onabotulinumtoxinA to incobotulinumtoxinA did not result in an inferior outcome for the treatment of facial dystonia and led to a cost-saving for the department.

Long-term outcome of flexible onabotulinum toxin A treatment in facial dystonia.

PURPOSE: The purpose of this study was to assess the long-term outcome of onabotulinum used to treat facial dystonia and compare a flexible and fixed treatment regimen. METHODS: This was a retrospective comparative study looking at benign essential blepharospasm (BEB), hemifacial spasm (HFS) and aberrant facial nerve regeneration synkinesis (AFR) treatment with onabotulinum toxin A (Botox®) over a minimum of 10 years. Fifty-one patients were recruited into the study, with each dystonia subgroup having 17 patients. Blepharospasm disability score (BDS), subjective improvement score (SIS), duration of maximal effect (DME) and complications were recorded at each visit. RESULTS: The mean age was 63 years and gender predominately female. Thirty-seven patients underwent flexible treatment intervals compared to 14 fixed treatment intervals, averaging 3.4 and 4 per annum, respectively. Mean BDS significantly improved from 6 to 3 at last review across all 3 groups, with the highest effect on BEB. BDS improvement was greater in flexible intervals. SIS remained similar for all three conditions during follow-up, but in those undergoing flexible intervals, SIS increased by a small margin compared to fixed interval. Mean DME was 10.5 weeks across all dystonias, but increased progressively only in the flexible interval group. Complications included ptosis (30%), dry eye (14%) and lagophthalmos (8%). CONCLUSION: Flexible onabotulinum provided better long-term relief on BDS for facial dystonia than a fixed regimen. Flexible interval treatment may also provide better patient satisfaction and longer DME compared to fixed treatment. Both have similar complication rates. With flexible treatment however, fewer injections were required over 10 years, leading to cost saving.

Comparison of equivalent keratometric indices on Scheimpflug tomography with Placido-based topography system at different optical zones.

AIM: To compare Holladay equivalent keratometric indices on Scheimpflug tomographer and keratometry on Placido topographer at different optical zones. METHODS: In this observational study, 50 right eyes of 50 patients were recruited. All patients were scanned on both machines. Data on K1, K2, mean keratometry (Km) and meridian of steepest keratometry (MoSK) were collected for central 3 mm and 5 mm optical zones from Holladay Equivalent keratometry report on Scheimpflug tomographer and keratometric data from Placido topographer. Difference (Diff(S-P)) in Km and MoSK were calculated by subtracting corresponding values of Placido from Scheimpflug scans. Concordance was evaluated using paired t tests, the Pearson correlation and Bland-Altman analyses. RESULTS: Comparing 3 mm vs 5 mm optical zones on each machine, there was no significant difference in Km and MoSK values but Km showed good correlation unlike MoSK. Comparing Scheimpflug versus Placido, Km showed good correlation at all scan sizes, unlike MoSK. 95% limits of agreement between the machines for Km was -1.20D to 1.08D(3 mm) and -1.46D to 1.23D(5 mm); whereas, for MoSK it was -83.05 to 85.82°s(3 mm) and -107.9 to 77.48°s(5 mm) respectively. The Diff(S-P) for Km at 3 mm (-0.45±0.79) was significantly less than that at 5 mm (-0.10±0.70) (p<0.01) whereas Diff(S-P) for MoSK were not significantly different at both optical zones. CONCLUSIONS: Mean keratometry correlated well between Scheimpflug and Placido scans. Axes showed poor correlation between optical zones on same machine and between the machines with same optical zone. Scheimpflug showed flatter keratometry at smaller optical zone. These machines cannot be used interchangeably in refractive surgery.