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Ask the Doctor 2013 Number 5 (September/October)

Disclaimer: neither the BEBRF nor members of the BEBRF Medical Advisory Board has examined these patients and are not responsible for any treatment.

Q: Can blepharospasm and/or cervical dystonia result in double vision? I have had both for 25 years. I have developed double vision in the last month or so. The eye doctor couldn't find anything eye-related. I know BOTOX® can create blurred and double vision because that happened a year ago, but I had my last BOTOX® in January so it's unusual for the double vision to come right before my next BOTOX®. There's pretty much blinking and neck movement now, so I need to find out if that can cause the double vision. I get it only when I look to the right or left, never when I'm looking straight ahead, and it seems to happen mostly when I'm walking and looking at moving people or animals.

A: Blepharospasm or cervical dystonia do not cause double vision and, if present, it should be investigated as a separate neurological disorder. Of course, botulinum toxin injections can cause double vision but that is a transient side effect that usually resolves in a few weeks.

Q: The VA has repeatedly denied claims for blepharospasm and Meige Syndrome for Vietnam Vets exposed to Agent Orange or for any other reason. I have read in numerous articles that tear gas causes temporary blepharospasm. Could there be a relationship between repeated exposure to tear gas and chemicals used in the Vietnam war? We were exposed to tear gas many times, causing severe eye pain and eye closure.

A: Tear gas consists of 2-chlorobenzalmalononitrile used as an aerosol of the volatile solvent in riot control and presumably also during warfare. This substance has been known to cause marked eye irritation and tearing, but to my knowledge, it does not cause permanent eye injury. Like any irritant, it can cause involuntary eye closure and transient blepharospasm. To my knowledge, however, it does not cause permanent blepharospasm, even with repeat exposures.

Q: Is there a brochure on sensory tricks? Is use of an oral orthotic appliance a trick or perhaps a weak approach to BEB relief? Sometimes I view botulinum toxin injections as a trick since it lasts only so many weeks and requires repeat injections.

A: I am submitting an article for publication on sensory aspects of movement disorders in which my co-authors and I discuss "sensory tricks" and suggest a new term, namely "alleviating maneuver", as this more accurately describes this phenomenon. Once the paper is published I would be happy to share it with the readers of the BEBRF newsletter. The most common alleviating maneuver for patients with blepharospasm is touching or pulling on the eyebrow, but there are many other examples. The so-called eyelid crutches (a wire appliance attached to the frame of glasses), most frequently used by patients with droopy eyelids, either as a result of eyelid weakness following botulinum toxin injection, or in patients who have excessive eyelid tissue as a result of chronic blepharospasm stretching the upper eyelid (called dermatochalasis), physically elevate the upper eyelid but may also serve as an alleviating maneuver. Some patients with blepharospasm also note that when they talk or sing they can keep their eyes open, which is a form of alleviating maneuver. It is possible that oral orthotic appliance can serve as an alleviating maneuver for patients with jaw dystonia, but I have never seen it used effectively by patients with blepharospasm. I do not believe that botulinum toxin injection is a form of alleviating maneuver as it acts by interrupting nerve impulses into the abnormally contracting eyelid muscles (orbicularis oculi). Furthermore, in contrast to self-applied alleviating maneuvers, the effects of which last only a few seconds or minutes, botulinum toxin relieves blepharospasm for several months.

Joseph Jankovic, MD, Director, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas

Q: I suffer from blepharospasm, and recently had a bout of digestive problems coupled with painful colon spasms. My gastro doctor prescribed Prilosec plus a pain medication called Hyoscyamine ER 0.375 MG tabs. One or two days after taking the pain med, I noticed that my blinking was minimal to not at all. I couldn't believe it so I stopped the medication, and my blinking returned. I waited a day and took it again with the same reaction of reduced blinking! I told my gastro doctor, and he smiled and said it was quite possible. I plan to take the med on those days when I have to drive long distances - it's a miracle!! Do you know about this medication and can I really use it to combat my blepharospasm?

A: This response makes good sense! The oral drug class that is most likely to improve blepharospasm is the anticholinergic class. Hyoscyamine is an anticholinergic. The more commonly used one in neurology is trihexyphenidyl (or Artane). Some patients do respond, actually a minority, so it is great that you do respond. Speak with your neurologist about possibly switching to trihexyphenidyl. Use carefully, monitoring for side-effects.

Q: In 2006, I was diagnosed with Meige and started BOTOX® injections, and using oral medications of baclofen and Artane. A few years ago, I voluntarily discontinued the usage of Artane, but am still using the baclofen. Since 2006, I have been exercising regularly, as in running, strength training, and stretching with classes like Pilates. In 2009, I was forced to retire early from my job (after 30 years) as public speaking was mandatory and I could not perform it.

It has been almost 4 months since my last BOTOX® injection. There are no restrictions on my driving ability. In fact, I drove 180 miles (each way) to my last three neurology appointments. My speaking ability is still limited, as in clearly articulating words; and I also have trouble with breathing when exercising (anaerobically). Both my speaking ability and breathing have improved since I stopped the BOTOX®, especially during the last three weeks. My neurologist has never had a patient who improved enough to stop the BOTOX® injections. I would like to know if this change is real.

A: There are rare remissions of focal dystonias, but this does happen. On the other hand, you are only 4 months from your last botulinum toxin injection and you are still taking baclofen. Hence, it is not clear that you have a full remission yet. In general, of course, we would recommend as little medication as possible for anyone. So for the moment, it is probably best to stay the course and see what happens in the next months.

Mark Hallett, MD, Chief, Human Motor Control Section, NINDS, NIH, Bethesda, Maryland

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