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Ask the Doctor 2014 Number 2 (March/April)

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

Q: It took a long time for my BOTOX® injections (100 units) to work and, even now, the results vary. When I had my last set, my forehead was still quite immoveable from previous injections, and my doctor discussed with me whether or not to inject there. However, I was worried I might not get good results and asked her to do it the same as the last few times when I did have very good results. Would it be better to not inject in that area when there seems to be quite a lot of BOTOX® present? Would that affect the overall result? Also, it usually takes up to a week to take good effect. Then I have been having about 7 weeks where I feel quite normal, then it starts to deteriorate. The last two weeks are quite horrid. My doctor does not want to inject before the usual 12 weeks. It has been almost two weeks since my injections and, though it is better, it has not improved that much, and I have a lot of blinking still. How can the results be so different? My doctor injected the same amount and at the same locations.

A: There are several questions here. First, in my experience, it is unnecessary to inject in the forehead area and, in fact, these injections may make it harder for patients with blepharospasm to open their eyes by paralyzing the muscle that lifts the eyebrows. Second, it generally takes 3 days for the toxin to start to take effect and maximal effects begin in approximately one week, so the time periods that are described are within the normal range. Some patients may have benefits earlier and some may take longer to reach maximal benefit. I have some patients that require injections sooner than 12 weeks and will inject as early as 8 weeks if necessary. Finally, sometimes injections work better than at other times. There are many variables that are at play with every injection cycle including the lot of toxin, the dilution of the medicine, and the actual injection technique used. Also, there may be variability in the patient's symptoms as well as underlying conditions including dry eye. It is important to use frequent lubrication with all injections, especially in the winter.

Andrew Harrison, MD, Director, Oculoplastic and Orbital Surgery, Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota

Q: My mother has blepharospasm, and I am just trying to do a little research as I think she may have gotten the wrong myectomy surgery. I am wondering if fascia is damaged in the process and if there is a possibility for laparoscopic surgery; or since the muscles must be cut, if the skin must be cut.

A: There are different types of myectomies for benign essential blepharospasm. All of them involve removing some of the muscles that close the eyes. Which myectomy is performed depends greatly upon each individual patient's needs. Practically speaking, there is no "fascia" in the eyelids to be damaged. Although a good question, performing a meticulous myectomy through an enodoscopic technique is both impractical and unnecessary. Skin incissions in the eyelids generally heal very well and are easy to hide. Skin removal, however, is NOT a myectomy. Don't confuse a blepharoplasty or even a droopy eyelid repair with a myectomy. If you have questions about the surgery, ask the surgeon who did the work. If you remain in doubt, seek a second, experienced opinion.

Charles N.S. Soparkar, MD, PhD, Plastic Eye Surgery Associates, Houston, Texas

Q: It seems there are many of the same characteristics of BEB present in Parkinson's disease (raised dopamine levels for one). Are we sure there is no connection? Are there other shared treatments besides Artane? What is the relationship if any?

A: There are connections between dystonia and Parkinson's disease. Specifically, there are often dystonic symptoms in Parkinson patients. Dystonia patients may have some Parkinsonian features, but this is not as common, and patients with blepharospasm generally do not. Exactly why there are the relationships is not completely clear, and this is the subject for ongoing research.

Q: If one accepts that many BEB patients are elderly and prone to balance problems, is ataxia more prevalent among them, and should BEB patients prepare for such?

A: Ataxia is not more prevalent in blepharospasm. Balance does become more difficult for everyone as they age, and, of course, it is difficult to balance if you are not seeing well. So blepharospasm might make balance more difficult by virtue of interfering with vision.

Q: I got a cortisone injection in the hip and noticed that my blepharospasm/apraxia improved. Why would this happen and would it be possible to get a cortisone injection once a month as a treatment for BEB?

A: There is no reason to think that a hip injection of steroid would improve blepharospasm. I suspect that it is a chance occurrence. The severity of blepharospasm does vary from time to time for unclear reasons. Perhaps if the hip was less painful, then the body would have less stress, and the blepharospasm might be better for that reason.

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

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