Botulinum toxin in neuro oph


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By : Busaba Sathornsumetee MD.
Mettapracharak Hospital

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Botulinum toxin in neuro oph

  1. 1. Functional use of Botulinumtoxin A in Neuro-Ophthalmology Busaba Sathornsumetee MD. Mettapracharak Hospital 31 August 2012
  2. 2. Benign EssentialBlepharospasm
  3. 3. BEB• Idiopathic focal dystonia• Involuntary intermittent bilateral eyelid closure• Women are affected more than men• Usually begins in the 4th -6th decade of life
  4. 4. Involved muscles• Orbicularis oculi• Corrugator• Procerus
  5. 5. Etiology• Unknown• No underlying causes• Parkinson disease, lower pontine lesion
  6. 6. Symptoms• Increased blinking (early)• Difficulty in eyelid opening (early)• Squeezing of the eyelids• Photophobia, eye pain, dry eyes• Functional blindness• Disturb daily activity, cosmetic
  7. 7. Signs
  8. 8. Differential diagnosis• Reflex blepharospasm• Eyelid myokymia• Early Hemifacial spasm• Apraxia of eyelid opening
  9. 9. Meige syndrome• BEB (often precede)• Oromandibular dystonia- Dystonia of lower face, jaw, neck
  10. 10. Management• Conservative treatment• Oral medication• Botulinum toxin injection• Myectomy
  11. 11. Botulinum toxin A for BEB (FDA approved 1989) (FDA approved 1989)• Advise Risk & Benefit• No contraindication for Botulinum toxin A injectionNeuromuscular disorder, Pregnancy-Lactation, Drug interaction• May stop ASA 7 days (cosmetic issue)• Cold pack for 5-10 mins (relieve pain & stop bleeding)
  12. 12. Potential adverse effects• Effect of the toxin on adjacent non-target muscles• Injection technique• Mild & transient effects
  13. 13. Potential adverse effects• Ptosis (7-11%)• Lagophthalmos (5-12%)• Symptomatic dry eyes• Diplopia (<1%)• Ecchymosis• Lower facial weakness
  14. 14. Site of injection for BEB- Orbicularis oculi (pretarsal part) * subcutaneous injection * medial & lateral area * 2.5-5.0 unit (upper) * 5.0-10.0 unit (lower)- Corrugator & Procerus * intramuscular injection * 2.5-5.0 unit
  15. 15. Failure of botulinum toxin• Inability of botulinum toxin to relieve squeezing• Problem of eyelid opening- Apraxia of eyelid opening (50%)- Dermatochalasis, Brow ptosis
  16. 16. Apraxia of eyelid opening• Inability to raise upper eyelid• Often occur with BEB• No eyelid squeezing , Elevation of eyebrow• Botulinum toxin + upper myectomy + tightening levator M.
  17. 17. Hemifacial spasm
  18. 18. Hemifacial spasm• Unilateral• Dystonia of facial muscles- Orbicularis oculi (precedes)- Zygomaticus major- Risorius- Mentalis• Normal ocular surface , Persist while sleeping
  19. 19. Hemifacial spasm• The whole face on one side contracts• Eyelid closure• Elevation of corner of mouth
  20. 20. Etiology• Hyperexcitability of the facial motor nucleus- Idiopathic- Ischemia or mass in pons (1%)• Compression of the facial nerve near its exit from the brainstem- Tortuous AICA- Dolichoectatic artery of the posterior circulation
  21. 21. Approach HFS• History takingDizziness, vertigo, ataxia, facial numbness, hearing lossDiplopia, facial palsy• ExaminationEOM, CN 5- 7- 8
  22. 22. Neuroimaging• Brain MRI (เน้น brainstem) + MRA with/without GAD• ตามตำาราแนะนำาให้ส่งทุก case• ใน clinical practice จริงๆ มีหลากหลาย- บางที่ส่งทุก case- เลือกส่งในบาง case มี neurological deficits อืนร่วม ไม่ตอบสนองต่อการรักษา ่
  23. 23. Management HFS• Oral medications (same as for BEB)• Chemodenervation with Botulinum toxin ADuration of action tends to be longer than in BEB• Microvascular decompression (craniotomy)
  24. 24. Microvascular decompression
  25. 25. Site for injection• Orbicularis Oculi +/- Corrugator• Zygomaticus Major (2.5-7.5 U)• Risorius (some cases, 2.5 U)• Mentalis (2.5-5 U)(Intramuscular injection for lower face)• ไม่แนะนำาให้ฉดบริเวณ Orbicularis Oris ี
  26. 26. Potential adverse effects• Same as BEB• Asymmetric smile• Drooping of the cheek and angle of mouth
  27. 27. How to decrease the adverse effect ?• Small dosage for Zygomaticus Major• Avoid Orbicularis Oris• Inject Botulinum toxin at Depressor Anguli Oris(DAO) or contralateral Zygomaticus major• Lower dose if secondary to facial palsy
  28. 28. Take home message• BEB is often a chronic progressive condition• Beware of other causes of treatment failure with botulinum toxin• Keep brain MRI in mind for HFS• Counselling is important before treatment
  29. 29. Thank you