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Ask the Doctor 2015 Number 1 (Jan/Feb/Mar)

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

  1. QUESTION: How do you tell the difference between blepharospasm and Myasthenia Gravis?

    ANSWER: Blepharospasm is a neurological disorder that causes involuntary and sustained muscle spasms of the muscles around the eyes. This causes increased blinking rates and twitching or spasms that can shut the eye closed. Myasthenia Gravis is an autoimmune neurological disorder that causes weakness of muscles that increases with use. When Myasthenia affects the eye muscles, patients have weakness of the eye muscles that can cause double vision or drooping of one or both eyelids. So in blepharospasm, there is excessive muscle activity affecting the muscles around the eye while in Myasthenia there is weakness of those muscles.

    Brian D. Berman, MD, MS, Movement Disorders Center, University of Colorado, Denver, Denver, Colorado

  2. QUESTION: I have blepharospasm and cervical dystonia and I also shake except when I sleep or yawn. I read an article on High Intensity Focused Ultrasound surgery that may help the dystonia. What can you tell me about it?

    ANSWER 1: HIFU is a new type of treatment for essential tremor, but this is an ablative procedure (creates a permanent lesion), similar to gamma knife radiosurgery or radiofrequency ablation. It can work in essential tremor, but treating a dystonic tremor is, in general, is more difficult. The best option for a Meige patient with tremor is probably deep brain stimulation.

    Mark Richardson MD PhD, Director, Epilepsy and Movement Disorders Surgery Brain Modulation Lab University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

    ANSWER 2: Focused ultrasound (FUS) is a relatively new treatment for movement disorders. There is good evidence only for essential tremor, but still larger studies are needed to be sure of its positive benefit to risk ratio. There are no studies for dystonia, and I suspect that the technique might not be as useful for dystonia.

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

  3. QUESTION: If you have had conjunctivitis, does this predispose you to getting blepharospasm?

    ANSWER: The triggers for developing blepharospasm are not really understood. If there is a relationship between conjunctivitis and blepharospasm, it must be quite loose. In my experience, the vast majority of people with blepharospasm have not reported a recent antecedent case of conjunctivitis, and there are many, many people who have had conjunctivitis who do not develop blepharospasm. A severe bout of conjunctivitis can certainly lead to a "dry eye" situation and most patients with blepharospasm do have a "dry eye" problem.

  4. QUESTION: When I have my eye spasms, I get almost a closing up of the nasal passages making it difficult to breathe. It is almost as if I make sounds blowing through my mouth trying to breathe. My nose seems to close up and I seem to be short of breath and struggling to breathe." Is this related and what can I do?

    ANSWER: I have heard this from some of my patients as well. These patients have such severe spasms that the whole mid-face spasms and puts pressure on the sinuses. If the eyelid injections don't work, your doctor might try injecting on either side of the nose in one or even two areas.

    Neil Miller, MD, Wilmer Eye Institute, Johns Hopkins, Baltimore, Maryland

  5. QUESTION: I have gotten BOTOX® injections for blepharospasm since the late 90s. My condition has gradually improved to the point now where I haven't had to get the injections in over a year. However, I developed another problem, and I don't know if it is related or not. At night, when I sleep, my facial muscles relax and my mouth opens and my eyes open somewhat. I have some kind of mucous in the corners of my eyes when I wake up. Can this be a side effect of getting the injections for so many years? What can be done about it?

    ANSWER: Resolution of blepharospasm symptoms is an extremely rare occurrence, but everyone would be delighted if this happened to you. Your sleep related muscle relaxation may also simply be a result of increased observation, but because of the mucous in the corners of your eyes, it does sound like a new symptom. The first question to consider is whether you notice this (suggesting you are not fully asleep) or if an observer reports the symptoms (and you are asleep). If it is sleep related, it may be simply a normal component of sleep, and although bothersome, does not suggest a new illness. If you are highly concerned, a sleep study will help sort this out. If the muscle relaxation happens when you are not asleep, it could represent long term effects of toxin injections. A nerve conduction velocity/electromyography (NCV/EMG) would help determine whether this is the cause. However, I would warn you that EMG of facial muscles are not for the faint of heart, and should be done by a neurologist with extensive EMG experience. One last thing, the mucous in the corners of your eyes, are likely only the drying of tear fluid that has collected in that location. You may wish to verify this at your next visit with an eye doctor.

    Mark Stacy, MD, Duke University, School of Medicine, Durham, North Carolina

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