Does blepharospasm effect biometric parameters and intraocular lens power calculations?

Patients with benign essential blepharospasm or hemifacial spasm are known to use botulinum toxin injections and alleviating maneuvers to help control their symptoms. The clinical correlates between the use of botulinum toxin injections and the use of alleviating maneuvers are not well established. To determine whether the use of alleviating maneuvers for benign essential blepharospasm or hemifacial spasm correlates with disease severity or botulinum toxin treatment. A prospective cross-sectional observational study (designed in September 2013) of 74 patients with benign essential blepharospasm and 56 patients with hemifacial spasm who were consecutively recruited from adnexal clinics at Moorfields Eye Hospital (January-June 2014) to complete a questionnaire and undergo a clinical review. Data analysis was performed in December 2015. Prevalence and type of alleviating maneuvers used for blepharospasm and hemifacial spasm, dystonia severity, and dose and frequency of botulinum toxin injections. Of the 74 patients with blepharospasm, 39 (52.7%) used alleviating maneuvers (mean [SD] age, 70.4 [9.1] years); of the 56 patients with hemifacial spasm, 25 (44.6%) used alleviating maneuvers (mean [SD] age, 66.5 [12.7] years). The most commonly used maneuver was the touching of facial areas (35 of 64 patients [54.7%]); other maneuvers included covering the eyes (6 of 64 patients [9.4%]), singing (5 of 64 patients [7.8%]), and yawning (5 of 64 patients [7.8%]). Patients with blepharospasm who used alleviating maneuvers scored higher on the Jankovic Rating Scale (median score, 5 vs 4; Hodges-Lehmann median difference, 1 [95% CI, 0-2]; P = .01) and the Blepharospasm Disability Index severity score (median score, 11 vs 4; Hodges-Lehmann median difference, 4 [95% CI, 1-7]; P = .01) than patients with blepharospasm who did not use alleviating maneuvers. Patients with hemifacial spasm who used alleviating maneuvers scored higher on the 7-item Hemifacial Spasm Quality of Life scale (median score, 7 vs 3; Hodges-Lehmann median difference, 4 [95% CI, 1-7]; P = .01) and the SMC Severity Grading Scale (median score, 2 vs 2; Hodges-Lehmann median difference, 0 [95% CI, 0-1]; P = .03) than patients with hemifacial spasm who did not use alleviating maneuver. The severity of dystonia correlated with botulinum toxin treatment for patients with blepharospasm (r = 0.23; P = .049) and patients with hemifacial spasm (r = 0.45; P = .001). There was no difference found in botulinum toxin treatment between patients who used alleviating maneuvers and those who did not, in either the blepharospasm group (150 vs 125 units; Hodges-Lehmann median difference, 20 units [95% CI, -10 to 70 units]; P = .15) or the hemifacial spasm group (58 vs 60 units; Hodges-Lehmann median difference, 0 units [95% CI, -15 to 20 units]; P = .83). Half of the patients with periocular facial dystonias used alleviating maneuvers. Their use was associated with more severe disease but not with increased use of botulinum toxin. This may help to guide future therapies, such as advice on maneuver augmentation or tailored devices.

Botulinum toxin(BTX)treatment is the first-line neurological treatment for hemifacial spasm(HFS). In my neurology clinic, Clinique Kita Neurologique(CKN), I have provided a cumulative total of approximately 400 BTX treatments for approximately 50 HFS patients for 23 years. Based on my own practical clinical experience, I have demonstrated the efficacy of BTX treatment. In compressive HFS, BTX treatment is indicated in patients who are not indicated or unwilling to undergo neurodecompression surgery. This is also indicated in the case of a long waiting period before surgery. In postparetic HFS, BTX treatment is indicated in patients with spasm and synkinesia. The amount of each BTX injection in postparetic HFS should be less than that in compressive HFS because of latent facial paresis. Although BTX injections can be easily administered in neurology outpatient clinics, it is important to perform the procedure safely and promptly.

Patient-reported outcomes following a break in ophthalmic botulinum toxin therapy during the COVID-19 pandemic

Introduction Botulinum toxin (BT) is a useful adjunct in the treatment of hypertonic pelvic floor muscles. By blocking the release of acetylcholine, a necessary neurotransmitter for muscle contraction, it facilitates muscle relaxation. These paralytic effects effectively disrupt painful muscle spasms and help patients make further progress in physical therapy when otherwise hindered by painful muscle spasms. Despite having robust data to support the off-label use of BT for the treatment of myofascial pain, there is limited data about its use for the treatment of pelvic floor myofascial pain. Additionally, there is no data about insurance reimbursement or the financial costs to patients undergoing pelvic floor muscle treatment with BT injections. Objective 1. Determine how many injections of BT patients receive for the treatment of hypertonic pelvic floor 2. Determine insurance reimbursement and financial costs to patients undergoing pelvic floor muscle treatment with BT injections. Methods Data was first collected by building a report in Epic to identify all patients seen in our department between 1/1/2022 to 10/31/2023 for a BT-related visit. Patient were further stratified based on CPT code 96372, indicating that they received pelvic floor BT injections. Fifty-one patients were identified. Charts were reviewed to determine how frequently patients returned for BT administration & to determine how much patients had to pay for BT treatment after filing with insurance. Results A total of 51 patients received pelvic floor muscle BT injections over the course of 61 patient encounters. Forty-three patients (84%) received BT once, 6 patients (12%) received BT twice, and 2 patients (4%) received BT 3 times. Of the 8 patients who required additional BT treatment, the average time between subsequent BT injections was 83 days. At our institution, the absolute charge for 100 units of BT was $1,068.16 without insurance. All patients treated had active insurance, and all 61 patient encounters were billed through insurance. At the time of this review, 20 patients encounters (33%) were still pending review with insurance, 41 patient encounters (67%) had been reviewed. Of these 41 patient encounters, 30 (73%) were accepted through insurance; 11 (27%) were denied. Nineteen administrations of BT were completely covered by insurance (no self-pay); 11 administrations of BT were partially covered through insurance. For patients that received partial or total coverage through their insurance company, the average self-pay cost for 100 units of BT was $66.77. Conclusions Most patients required one visit for pelvic floor muscle treatments with BT, and only occasionally required more than one visit. Prospective studies are needed to quantify and quality patient’s improvement in pain following each BT treatment. In the majority of cases, when BT was filed through insurance, it was at least partially approved. Without insurance, the charge for 100 units of BT was $1,068; when approved through insurance, the average self-pay cost for 100 units of BT was $66.77. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Patty Brisben Foundation.

53. Is the facial nerve injured by a vascular compression in hemifacial spasm? Stimulating single-fiber EMG study

Re: Hoffer et al.: Update on intraocular lens power calculation study protocols: the better way to design and report clinical trials (Ophthalmology. 2020; Jul 9 [Epub ahead of print

Purpose: The purpose of this work was to conduct a comprehensive literature review of the challenges encountered in ocular biometry and intraocular lens (IOL) power calculations in patients with keratoconus undergoing cataract surgery and to evaluate the performance of various biometric techniques and IOL power calculation formulas in this population. Methods: A comprehensive literature search was conducted in PubMed for studies published until October 2025. Keywords included "keratoconus", "biometry", "IOL power calculation", "cataract surgery", "keratometry", and related terms. Studies evaluating the repeatability of biometric measurement, the accuracy of IOL formulas, and surgical outcomes in keratoconus patients were included. Study quality was assessed using standardized criteria, including study design, measurement standardization, and statistical appropriateness. Results: Twenty studies comprising 1596 eyes with keratoconus were analyzed. Biometric challenges include reduced keratometry repeatability (especially with K > 55 D), altered anterior-to-posterior corneal curvature ratios, anterior chamber depth, unreliable corneal power measurements, and tear film instability affecting measurement consistency. Keratoconus-specific formulas (Barrett's True-K for keratoconus and Kane's formula for keratoconus) demonstrated superior accuracy compared to standard formulas. The Barrett True-K formula with predicted posterior corneal astigmatism showed median absolute errors of 0.10-0.35 D across all severity stages, with 39-72% of eyes within ±0.50 D of target refraction. Traditional formulas (excluding SRK/T) produced hyperopic prediction errors that increased with disease severity. Swept-source optical coherence tomography biometry with total keratometry measurements improved prediction accuracy, particularly in severe keratoconus. Conclusions: IOL power calculation in keratoconus remains challenging due to multiple biometric measurement errors. Keratoconus-specific formulas significantly improve refractive outcomes compared to standard formulas. The use of total keratometry and swept-source OCT biometry, as well as the incorporation of posterior corneal power measurements, enhances accuracy. A multimodal approach combining advanced biometry devices with keratoconus-specific formulas is recommended for optimal outcomes.

Laryngeal dystonia (LD), or spasmodic dysphonia (SD), is a neurological disorder characterized by focal dystonia or involuntary spasms of the laryngeal muscles and associated voice symptoms. It is typically treated with injection of botulinum toxin (BoNT) that weakens the affected muscles. The primary purpose of this qualitative study was to explore participants' experience of living with LD and BoNT treatment. The secondary purpose was to examine those experiences as a function of participants' scores on the Communicative Participation Item Bank (CPIB). Results will enhance our understanding of restrictions in communicative participation, assist in planning intervention targeting these restrictions and aid in clinical interpretation of CPIB scores. Semi-structured interviews using a phenomenological tradition and focusing on BoNT treatment and communicative participation were conducted with 26 people with LD who are on established BoNT treatment regimens. Interviews were recorded, transcribed, coded and analysed inductively. Participants were categorized by CPIB scores into groups ranging from none to extensive participation restrictions. Both self- and expert ratings of voice were obtained. Participants with different levels of CPIB scores had different experiences related to communicative participation in the context of BoNT treatment. These differences were organized into the following topics: BoNT and voice; attitudes toward participation; coping strategies; and advice. For all participants except those in the least restricted and most restricted groups, expert ratings of voice did not relate to CPIB scores. Although most participants report improved voice with BoNT treatment, many participants experienced lingering restrictions in communicative participation, some to a severe extent. Participants reported coping with these restrictions in many ways; some of these strategies were more successful than others. Those with restricted participation recommended more support for daily life and the emotional toll of LD, as well as support for family members. This support might be offered by speech-language pathologists. What is already known on the subject Participants with different levels of CPIB scores had different experiences related to communicative participation in the context of BoNT treatment. What this study adds to the existing knowledge Although most participants report improved voice with BoNT treatment, many participants experienced lingering restrictions in communicative participation, some to a severe extent. What are the potential or actual clinical implications of this work? SLP services that take a participation-focused approach to intervention and use multi-factorial approaches to help clients maximize their life participation in the context of LD are well within the SLP scope of practice. SLPs can help clients find and use their optimal voices within the constraints of the dystonia and BoNT effects.

ABSTRACTObjective: To investigate the treatment effects of botulinum toxin-A (BTA) injection and acupuncture on blepharospasm (BP) evaluated by the change in lower eyelid tension (LET).Methods: A series of 30 patients (male: 8, female: 22) aged between 37 and 83 years (63.80 ± 10.96 yrs) who met the eligibility criteria of BP were recruited in this study, who were randomly assigned to BTA injection group (BTA group, n = 15) and acupuncture treatment group (Acupuncture group, n = 15). BTA injections were administered to the patients in BTA group while patients in acupuncture group received the acupuncture treatment. The LET was measured by a tensiometer in both groups at baseline and at post-treatment.Results: A significant decrease in LETs over 8 weeks was found in acupuncture group (812.76 ± 193.95 Pa at baseline, 549.69 ± 150.04 Pa at 4 weeks, and 510.96 ± 150.66 Pa at 8weeks, respectively; F = 31.127, p << 0.001). There was a significant decrease in LET from 858.61 ± 190.54 Pa at baseline to 414.45 ± 63.38 Pa at 2 weeks after treatment (Z = −4.542, p << 0.01) in BTA group. At the endpoint of the study, a significant difference in LET was found between the acupuncture group (301.80 ± 181.77 Pa) and the BTA group (444.16 ± 193.44 Pa) (t = −2.077, p = 0.047).Conclusions: BP patients have an increased LET. Both BTA and acupuncture are effective in decreasing the LET. Close monitoring of LET holds promise in planning the treatment strategy for Blepharospasm.

Hemifacial spasm (HFS) is a condition causing poor quality of life. Treatment with botulinum toxinA (BTX) injection is effective. Only one randomized controlled trial with a single-blind fashion has evaluated if oral injection is needed in HFS. The present study aimed to evaluate the necessity of oral BTX injection in HFS by a randomized, double-blind, placebo-controlled method. We conducted a double-blind, placebo-controlled trial in patients with HFS who never received BTX treatment. Eligible patients randomly received either 15units of BTX around the eye and normal saline around the mouth (groupA) or 15units of BTX around both the eye and the mouth (groupB). The primary outcomes were self-reported symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the injection and the recurrence of symptoms to the same condition as before treatment. Student ttest and survival analyses were used to compare the duration of symptoms between both groups. The mean changes were compared to secondary outcomes between the two groups. There were 60 patients enrolled, half in each group. Baseline characteristics between both groups were similar. The mean (SD) of the duration of improvement in groupA and B was 22.97 (18.85) and 17.53 (14.90)weeks, respectively (p = 0.220). There was no difference between both groups by survival analysis. GroupB had a higher percentage of mouth improvement but there was no difference in the percentage of eye improvement, visual analog scale of eye and mouth spasm, or frequency of eye and mouth spasm. GroupB had a higher incidence of side effects particularly mouth drooping (30% vs 10%) than groupA (p = 0.053). The mouth injection of BTX may not be necessary for HFS. It may be beneficial to reduce mouth symptoms with a higher rate of mouth drooping.

Botulinum toxin improves quality of life in hemifacial spasm: validation of a questionnaire (HFS-30)

Purpose: To find out the results of prolonged Botulinum toxin A on its duration of action in patients with blepharospasm and hemifacial spasm. Study Design: Prospective Case series. Place and Duration of Study: Yaqin Vision center from 2010 to Dec 2016. Material and Methods: All patients of both genders who were treated with Botulinum toxin for treatment of hemifacial spasm and blepharospasm were included in the study. Patients were divided into 2 groups, Group 1 included all patients who had 2-5 injection while group 2 included all patients who had 5-19 injections of botulinum toxin A. Patients with secondary blepharospasm due to drugs, ocular and neurological disorders were excluded from the study. Patients with blpharospasm were injected botulinum toxin A at 7 periocular sites on both sides while patients with hemifacial spasm were injected at 7 periocular and 6-7 perioral sites (orbicularis oris, levator labi, zygomaticus major, mentalis and platysma). Onset of effect of botulinum toxin A and duration of action was recorded for all patients. Results: Total 257 injections were given to 40 patients with an average of 6.43 injections (range 2-19). The mean age of patients was 51 ± 12.1 years. Male to female ratio was 1:1.1. Mean onset of action in Group 1 was 3.81 ± 2.6 days and in Group 2 was 3.92 ± 3.4 days after injection. Average 51.13 units of botulinum toxin A were injected in each injection. Mean duration of botulinum toxin A efficacy in Group 1 was 3.43 ± 1.5 months and in Group 2 was 3.26 ± 1.6 months. Non-significant p-values of 0.41 for onset and 0.23 for duration were found. Conclusion: After prolong use of botulinum injection mean duration of action remains almost same. Keywords: Blepharospasm, Hemifacial spasm, Botulinum toxin

Intrasphincteric injection of botulinum toxin (BTX) and removable self-expanding metal stents (SEMS) have both been used for the treatment of achalasia. To compare the effectiveness and long-term outcome of SEMS placement and BTX injection in patients with achalasia. A total of 110 patients with newly diagnosed achalasia were enrolled in the study between July 2003 and December 2009. The patients received either BTX injection (n = 51) or SEMS placement (n = 59). Clinical symptoms, objective parameters, and long-term clinical outcomes were evaluated after 7 and 30 days and then every 6 months until withdrawal from the study. The mean duration of follow-up was 28 months (range 10-36 months). Improvements in global symptom and dysphagia scores and in basal lower esophageal sphincter pressure were significantly more marked in the SEMS group than in the BTX group (all P < 0.05). After 12 months, the remission rate in the SEMS group (81.28 %) was statistically significantly higher than that in the BTX group (64.58; P < 0.05). At 36 months, the remission rates in the two groups were 49.1 and. 4.2 %, respectively (P < 0.01). The symptom-free interval was 831 ± 46 days in the SEMS group and 522 ± 42 days in the BTX group (P < 0.01). No side effects were reported with BTX treatment. In the SEMS group there were 13 episodes of chest pain, nine cases of regurgitation, and four stent migrations. No serious complications occurred. Removable SEMS was associated with better long-term outcomes than BTX injection in patients with achalasia.

BackgroundAssociative high-frequency electrical stimulation (HFS) of the supraorbital nerve in five healthy individuals induced long-term potentiation (LTP)-like or depression (LTD)-like changes in the human blink reflex circuit according to the rules of spike timing-dependent plasticity (Mao and Evinger, 2001). HFS given at the onset of the R2 component of the blink reflex (HFSLTP) produced a lasting facilitation of the R2, whereas HFS given shortly before R2 (HFSLTD) caused a lasting suppression of the R2. In patients with benign essential blepharospasm (BEB), a focal dystonia affecting the orbicularis oculi muscles, HFSLTP induced excessive LTP-like associative plasticity relative to healthy controls, which was normalized after botulinum toxin (BTX) injections (Quartarone et al, 2006).Methodology/Principal FindingsWe used HFS conditioning of the supraorbital nerve to study homeostatic metaplasticity of the blink reflex circuit in healthy subjects and dystonic patients. On separate days, we tested the conditioning effects on the R2 response and paired-pulse R2 inhibition after (i) HFSLTP, (ii) HFSLTP followed by HFSLTP, and (iii) HFSLTP followed by HFSLTD. Controls also received (iv) HFSLTD alone and (v) a non-intervention protocol. In BEB patients, HFSLTP followed by HFSLTD was given before and after BTX treatment. We were not able to replicate the bidirectional timing-dependent effects of HFSLTP and HFSLTD alone. All HFS protocols produced a non-specific reduction of the R2 response and a relative decrease in paired-pulse inhibition. These R2 changes also occurred in controls when no HFS was applied. There was also no trace of a homeostatic response pattern in BEB patients before or after BTX treatment.Conclusion/SignificanceOur data challenge the efficacy of associative HFS to produce bidirectional plasticity in the human blink reflex circuit. The non-specific decrease of the R2 response might indicate habituation of the blink reflex following repeated electrical supraorbital stimulation. The increase of inhibition after paired pulse stimulation might reflect homeostatic behaviour to prevent further down regulation of the R2 response to preserve the protection of this adverse-effects reflex.

The objective of this study is to investigate the changes of urothelial junction proteins, apoptosis and suburothelial inflammation after detrusor injection of botulinum toxin A (BoNT-A) in patients with spinal cord injury (SCI) and neurogenic detrusor overactivity (NDO). A total of 26 patients with chronic suprasacral SCI and NDO were enroled. The urothelium was assessed by cystoscopic biopsy at baseline, 3 and 6 months after a single treatment of 300 U BoNT-A into the detrusor. Immunofluorescence staining of E-cadherin, zonula occludens-1 (ZO-1) and tryptase for mast cell activity were performed. Urothelial apoptosis was also evaluated. The differences in urothelial dysfunction were compared between baseline and 3 and 6 months after treatment. Bladder biopsies from patients undergoing anti-incontinence surgery served as controls. A single 300-U BoNT-A injection into the detrusor significantly decreased detrusor pressure and increased bladder compliance at 3 and 6 months after treatment. Significantly lower E-cadherin and ZO-1 expressions and increased mast cell and apoptotic cell counts were noted in SCI bladders compared with controls (all P<0.001). Significantly greater distributions of E-cadherin (P<0.001) and ZO-1 (P=0.05) expressions were noted 3 months after BoNT-A injection. However, these changes had declined by 6 months after treatment. Activated mast cells and urothelial apoptosis showed no significant differences between baseline and 3 or 6 months. Urothelial dysfunction and adhesive and junction protein concentrations in SCI patients' bladders recovered after BoNT-A treatment. However, this effect decreased with time. Thus, neurogenic inflammation after SCI was not adequately improved after a single BoNT-A injection.