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Ask the Doctor 2015 Number 3 (July/Aug/Sept)

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: I have been suffering from Blepharospasm for over 6 years and have been receiving my monthly Botox injections which help somewhat. I have noticed that in the past year or two I have had progressively dry mouth and lips. I find it necessary to have candy in my mouth most of the day just to make saliva. Since I have pretty much ruled out my other medication I'm on I am now wondering if this could be attributable to the Botox build up in my system or is just a progressions of the Blepharospasm. Can you give my any opinion based on your experience what could be causing this.

    ANSWER: Dry mouth can be an acute effect of botulinum toxin injection, seen mostly with high doses such as with injections for cervical dystonia, and would fade before the next injection. This would not be common for blepharospasm injections. The gradual development of continuous dry mouth would not be typical and does suggest something like Sjogren's syndrome. On the other hand, I see that the question states monthly injections. Injections are most commonly given every three months. If injections are actually given monthly, I suppose it might be possible that the dry mouth sensation would be continuous.

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

  2. QUESTION: I have been treated for BEBRF for many years and have found great benefit from Botox. My question is, can BEBRF be caused by or have any relationship to under water diving/hyperbaric chamber diving and or military service?

    ANSWER: There is no evidence that blepharospasm has any "relationship to under water diving/hyperbaric chamber diving and or military service"

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

  3. QUESTION: I love to drink beer. I'm 58, in good shape, all the test I've had recently have been fantastic. (except for the blepharospasm thing) Is there any connection to drinking alcohol and this disorder.

    ANSWER: There is no evidence that alcohol causes blepharospasm. However, many patients with blepharospasm have an associated condition, called essential tremor, manifested by shaking of the hands, head, voice, etc. Essential tremor often transiently responds to alcohol as a result of which many patients with essential tremor (and blepharospasm) drink alcohol. Unfortunately, excessive consumption of alcohol can cause neurological (and other) damage and can eventually exacerbate the tremor and other associated neurologic conditions.

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

  4. QUESTION: My first injection of Botox was on the light side. I guess that's pretty typical. So, I'm still having the eyes opening and closing involuntarily. While riding in the golf cart this weekend, I experienced a great deal of motion sickness. Has anyone else ever reported this? Is this a normal side effect?

    ANSWER: Motion sickness is unlikely to be related to periocular Botox injections.

    Andrew R. Harrison, MD, Director, Departments of Ophthalmology and Otolaryngology, University of Minnesota, Minneapolis, Minnesota

  5. QUESTION: I'm new to this and had my first Botox injection on Monday. So we're keeping our fingers crossed. I had a friend ask me today if accu-puncture is ever considered in the treatment of this disorder.

    ANSWER: There are no scientific studies that show any clear added benefit for acupuncture treatments in patients with blepharospasm. I do not recommend it for my patients. That being said, anecdotally I do have some patients who feel that they do get some benefit from acupuncture treatments

    Andrew R. Harrison, MD, Director, Departments of Ophthalmology and Otolaryngology, University of Minnesota, Minneapolis, Minnesota

  6. QUESTION: I was diagnosed with blepharospasm four years ago, and have been taking BOTOX® shots every month. The past couple of months, my throat is progressively getting dryer with each week. Is this considered a new stage in blepharospasm or does this sound like it could be caused by my blepharospasm getting worse or does it not seem to be associated with blepharospasm. Either way I intend to go to a throat specialist but thought any feedback you might be able to render would help him diagnose what is happening to me.

    ANSWER: Botulinum toxin can cause dry mouth, but that symptom would come and go with each injection. And it is not likely to occur with the relatively small doses used for blepharospasm. Otherwise there is no obvious relationship to dry throat and you do need to see your doctor.

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

  7. QUESTION: I am 60-years-old and have been diagnosed with hemifacial spasm. The spasm affects my left eye. I started noticing this about 2 years ago when I began wearing prescription bi-focal lenses for 4 or 5 hours a day working on the computer. When I removed the glasses, the spasms would begin to subside somewhat until after I had slept all night, I didn't notice them at all. Now, I need to wear the glasses all day and am required to wear them when I drive, but the spasms are really bad and don't subside as much as they used to, although they seem to be gone in the morning after I sleep until I put my glasses back on. Also, I had a brainstem injury 18 years ago when I fell that caused me to suffer from insomnia. I have been taking doxepin for that - starting out with 300 mg but am now down to 50 mg daily. Why would the prescription lenses make the spasms worse and would the injury or the doxepin contribute to it?

    ANSWER: Assuming that you indeed have hemifacial spasm, it is difficult to explain why prescription glasses or doxepin would have any meaningful and consistent effect on the facial spasms. The most common form of hemifacial spasm, due to compression or irritation of the facial nerve by an artery in the posterior aspect of the skull, typically fluctuates from minute to minute and day to day. It is, therefore, not unusual for patients to attribute the waxing and waning to some factor, such as stress, lack of sleep, or even glasses. Since you apparently had a brainstem injury it is possible that your hemifacial spasm may be due to some other cause. In either case, botulinum toxin injections, administered by a skilled and experienced clinician, should help to control the involuntary spasms.

  8. QUESTION: I have Parkinson's disease. Recently I went to an ophthalmologist who told me I did not have blepharospasm, that I have dry eye syndrome and apraxia of eyelid opening. My eyes close on me, and I have a difficult time opening them even with my fingers. He said I need eye drops several times a day and a gel at night. He also told me BOTOX® would not benefit me unless I have spasms in my eyelids. I'm in a dilemma - what can I do?

    ANSWER: Dry eye syndrome often accompanies blepharospasm but may be also associated with apraxia of eyelid opening. The latter condition is manifested by inability to open eyes after they close. This condition is different from blepharospasm although both can co-exist in the same individual. While in most cases no specific cause can be found for blepharospasm (i.e. "essential blepharospasm"), apraxia of eyelid opening is often found in the setting of Parkinson's disease or some other parkinsonian disorder. Without examining you it would be impossible to confirm the diagnosis of apraxia of eyelid opening, but it is not correct that this condition does not respond to botulinum toxin. When injected by a skilled and experienced physician, botulinum toxin can be quite effective in improving apraxia of eyelid opening, particularly if it is associated with or triggered by blepharospasm.

  9. QUESTION: I've had blepharospasm for 15 years and have just developed Meige also. Can I expect BOTOX® injections to help with the facial spasms as well as my BEB? Are there specific areas I should discuss with my neurologist for injection sites and quantity of the toxin for each injection?

    ANSWER: Patients with blepharospasm often develop spasms (dystonia) of other parts of the face and mouth including the jaw and tongue. Sometimes the term "Meige syndrome" is applied to the combination of blepharospasm and oromandibular dystonia, but we prefer the term "cranial dystonia." In some cases the dystonia progresses to also involve the neck, the so-called "cranial-cervical dystonia." Botulinum toxin injections are usually very effective in treating not only the blepharospasm but also the other aspects of the "cranial-cervical dystonia." The type of injection and the dosage are dependent on the muscles involved, skills of the neurologists, and the methods of injection.

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

  10. QUESTION: My spasms often correspond to my stress level. Is there any information on the benefits of relaxation techniques such as yoga and massage therapy or medication?

    ANSWER: It is pretty much universally accepted that there is an association between stress and blepharospasm. I can find very little published research that has formally studied this relationship, but it is often quite evident in clinical practice. There is an interesting article published in the Journal of Neuro-ophthalmology, 2007 Dec:27 (4): pages 275-280, which found a link between blepharospasm and stressful life events, but obviously this is an area that needs more research attention.

    That said, given the stress and anxiety that we so often see in our patients, I very much support relaxation techniques and exercise as interventions. Actually, I encourage relaxation techniques and exercise for everyone… life can be challenging for all of us! You should certainly clear you plan with your physician(s) before beginning. And I encourage you to try activity that appeals to you, that is comfortable for you, and that is realistic given your time available and your financial situation. Patients should also keep in mind that, with relaxation techniques and exercise programs, they may want to sample a few different ones to see which works best for them. It is very much a "different strokes for different folks" situation. What one person enjoys and benefits from may be different from the person next door. If you have something already in mind, you should go for it. But if you want some ideas, a good resource is Nathan and Charlesworth's book, Stress Management which provides a good overall view of many approaches.

    Relaxation and exercise activities can be beneficial from a couple of perspectives. One is the physiological response of the body, the release of the good hormones and the dissipation of the bad hormones, the relaxation of muscle tone, etc. But another perspective is that engaging in these activities is a means of enhancing our feeling of being in control. Blepharospasm has a way of making us feel victimized with our sense of control compromised. Refusing to do nothing, revving up, and engaging in healthy activity, are wonderful ways to grab back some personal power.

    Julia J. Kleinschmidt, PhD, LCSW, Emeritus Professor, Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah

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