Developments in the Treatment of Benign Essential Blepharospasm

Michael T. Yen

Disclosures

Curr Opin Ophthalmol. 2018;29(5):440-444. 

In This Article

Surgical Management

Surgical intervention is usually recommended when patients with BEB do not tolerate or respond to medical therapy and continue to have significant impairment. The goal of surgical intervention is to improve functionality in patients affected with blepharospasm. It can also reduce the severity of the spasms, increase the period between botulinum injections, and improve the associated secondary eyelid and facial changes found in patients with blepharospasm.

Various surgical options have been described from peripheral facial neurectomy to various types of myectomies. Different techniques have been described for peripheral facial neurectomy; however, there is typically a high-recurrence rate and associated side effects, such as paralytic ectropion, epiphora, and facial droop. In addition, these patients usually require secondary procedures to correct the induced paretic eyelid malposition. For these reasons most physicians have stopped using peripheral facial neurectomy, now leaning toward surgical myectomy as the first surgical treatment to consider in BEB.[18]

Surgical myectomy involves the resection of the protractor musculature (namely, the orbicularis oculi, corrugator, depressor supercilii, and procerus). A blepharoplasty with muscle excision was initially described in the 1950s and involved the sparing of the pretarsal orbicularis oculi.[19] In 1981s, the full myectomy was described by Gillum and Anderson,[20] with excellent results in controlling blepharospasm; however, this procedure often had adverse postoperative sequelae such as persistent lymphedema, facial anesthesia, and lagophthalmos. Despite the complications, Anderson et al.[4] found that full myectomy resulted in 88% improvement in patients with blepharospasm. A limited upper eyelid myectomy technique has been used for patients who have a decreasing response to botulinum toxin A, and has far fewer complications compared with a full myectomy (Figure 3). Lower eyelid myectomy is generally reserved for patients who continue to have severe blepharospasms after an upper eyelid myectomy. Lower eyelid myectomy can be complicated by lower eyelid retraction, ectropion, and lymphedema. In addition, in refractive cases of blepharospasm, after myectomy and botulinum toxin injections, differential sectioning of the facial nerve has been reported to benefit patients as an adjunctive procedure.[21]

Figure 3.

Through an eyelid crease incision in the upper eyelid, a limited myectomy can be performed to remove the (a) pretarsal as well as the (b) preseptal and orbital orbicularis oculi muscle.

It is difficult to estimate the percentage of patients who are completely free of the need for botulinum toxin after surgery, although in general, the dose required is lower and the intervals between injections is lengthened. In 1999, Chapman et al.[22] followed up on 54 patients with essential blepharospasm who underwent eyelid protractor myectomy at Mayo Clinic from 1980 to 1995. They found that patients who had been treated with botulinum toxin injections before receiving myectomy were more likely to receive injections postoperatively than patients who had not been treated previously with botulinum toxin. In this case series, the overall probability of receiving botulinum toxin 5 years after surgery was 46%. After myectomy there is often a volume deficit from the extensive muscle excision, which can often be esthetically undesirable. Free orbicularis oculi muscle grafts can be useful adjunct to correct these volume deficit deformities during surgical myectomy.[23]

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