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Surgical Correction of Intractable Blepharospasm
788
A. E. MAUMENEE
ing. Thus, they are carrying basic research activities into patient care. It is planned that, when appropriate persons become available either through our residency training program or from other institutions, we will continue to add to our clinical faculty until the major fields of interest in clinical ophthalmology are covered. Persons in this category will see a limited number of patients, usually those referred for consultation, and will participate in the teaching program of the house officers and medical students, and will maintain an active interest in investigative work. The attending staff of the Institute will be restricted to those ophthalmologists who have proven themselves to be capable physicians and who have demonstrated an interest in teaching and research. No specific affiliations of the Institute with other eye clinics, services or hospitals are planned at the present time. However, we will continue to assist in the teaching program of local eye services, and will maintain and strengthen our relations with the Baltimore City Hospital
and the Veterans Hospital. If other services become available in the future with which it will be mutually advantageous for the Wilmer Institute to become closely affiliated, these arrangements will be carefully considered. Thus, the future plans for the Wilmer Institute do not hold major departures from the past. The new facilities and those already available in the Wilmer Institue will serve to house the modern, complicated instruments for research, and the teams of workers needed to carry out the investigative activities. The purposes of the Institute will be as they have been in the past : to train the best clinicians that we are capable of producing ; to instill in these persons a scientific approach and an interest in investigation ; to offer the best possible patient care; to produce excellence rather than volume in laboratory investigation ; and constantly to transform knowledge acquired in the laboratory into improved care for patients. The Johns Hopkins Hospital (5).
SURGICAL CORRECTION O F INTRACTABLE BLEPHAROSPASM TECHNICAL IMPROVEMENTS ALSTON CALLAHAN,
M.D.
Birmingham, Alabama
Since the publication in October, 1963, of an operation to lessen the contractile force of the orbicularis muscle in severe intractable blepharospasm, my experience has increased with three recurrences, seven more patients referred with this condition, and one sent for this operation who did not need it. Lessons learned from these patients and further operative procedures devised for some of the more resistant cases seem to justify publication of this additional information. Also, I have now read John Warren Henderson's illuminating report on the clinical
course of 135 patients with "essential blepharospasm" (meaning idiopathic blepharospasm). He believes that an organic basis for essential blepharospasm exists in the brain somewhere higher in the course of neuronal synapses than the facial nucleus in the pons. Henderson found that injection of alcohol into the facial nerve was not justified by the results. He did not find excision of a portion of the orbicularis muscle satisfactory and the most effective relief of symptoms among the patients he personally treated was achieved by resecting the main trunk of the facial nerve distal to the stylo-
INTRACTABLE BLEPHAROSPASM
789
Fig. 1 (Callahan). The facial nerve supply to the left orbicularis muscle. The motor nerve supply for the orbicularis muscle extends from the temperofacial division of the facial nerve. This division is made up primarily of the temporal, upper and lower zygomatic branches which lie in the submuscular fascia and interlay with each other. The temporal and upper zygomatic branches supply the muscles of the eyebrow in the upper half of the medial canthus. The lower zygomatic supplies the lower part of the orbicularis in the lower half of the medial canthus. The lateral part of the orbicularis is supplied by both zygomatic branches. mastoid foramen, but he recommends this only for severe blepharospasm associated with extensive spasms of other muscles of the face innervated by the facial nerve. It is easy to miss the diagnosis because the patient usually says, " I can't see," focusing attention on the eyes. If he would say, " I can't hold my eyelids open," the condition would be recognized immediately. Lester T . Jones' dissections of the anatomy and considerations of the physiology of the lid comprise the first section of the recently published Tumors of the Adnexa by Merrill Reeh. H i s study of the facial nerve supply to the orbicularis muscle furnished the information for F i g u r e 1 ; it shows how the nerve extends deep into the fascia and is comprised of a network of branches and anastomoses and rebranches which enter the muscle from behind. I n the operation, the branches are not identified, but the lateral band of the orbicularis muscle is resected and the resection is extended along an area higher than the eyebrow, and down in the cheek tangent to the orbicularis (fig. 2 ) .
T h e danger of complete facial paralysis is avoided by not extending the dissection and resection back toward the ear. If the frontal is also contracts as part of the blepharospasm, as evidenced by a Z-shaped kink over the corrugator, an incision should be made through the medial third of the brow and the attachment of the corrugator to the skull should be divided. The three patients who developed recurrences after being initially helped by this operation stated that they found it difficult to elevate their lids. Examination showed that, although the orbicularis muscles were adequately weakened, senile ptosis had developed, perhaps increased by the overriding strength of the orbicularis muscles which had existed for months or years. F o r this condition, as for ordinary cases of senile ptosis, the levator muscles are shortened by tucking (fig. 3 ) . Another of the patients, whose uncontrollable squeezing of the orbicularis recurred, found he could not read when he held the reading material in the normal position be-
ALSTON CALLAHAN one developed by Lester T. Jones and his co-workers for the correction of senile entropion (fig. 4 ) . It was mentioned that one patient was referred for this operation without proper indications. She said that she could not keep her eyes open and that she could not read and that she had to hold her eyes open with her fingers. She had vision without correc-
Fig. 2 (Callahan). Resection of facial nerve supply to orbicularis muscle. About 10 cc. of lidocaine (Xylocaine®*) mixed with hyaluronidase (Wydase®*) are injected along the posterior lateral border of the orbicularis muscle approximately 2.5 cm posterior to the lateral canthus. A curvilinear incision is made in the area of injection and the posterior lateral border of the orbicularis is exposed. A sector of the muscle, about 10-mm wide and 40 to 50-mm long around the lateral curve, is excised, removing the muscle and deep fascia until the periosteum is cleared. For extremely severe blepharospasm, a wider and longer orbicularis section can be removed, as shown by the dotted angles. * Astra Pharmaceutical Products, Inc., Worcester 6, Massachusetts. * Wyeth Laboratories, Philadelphia.
cause the margin of the lower lids rose higher than the level of the pupils. A functional and anatomic change of the lower lid noted in some of these patients is atrophy of the inferior orbital septum ; and the pretarsal and preseptal portions of the orbicularis muscle over a period of time had stretched the lid to make it rise too high. T o strengthen and shorten the inferior orbital septum and correct this part of the intractable blepharospasm, a part of the preseptal orbicularis is resected and the septum is tucked in, an operation modified from the
Fig. 3 (Callahan). Tucking of the levator palpebrae superioris. (A) Through a skin incision at the upper tarsal border, the orbicularis fibers are separated and the levator and Mueller's muscles and tendons are exposed; mattress sutures of gut (chromic 4-0) are inserted in the levator for an appropriate distance above the tarsus and then brought through the tendon at the upper range of the tarsus. (B) As these sutures are tied, the effectiveness of the levator is increased and the patient is able to elevate his lids higher.
INTRACTABLE BLEPHAROSPASM
791
tion of 20/20 in each eye and, when seen on three successive days, her eyes remained open, with a normal blink reflex which did not set off an orbicularis clamplike contraction. What her psychologic trauma or motivation was is not known. She was sent back to the referring ophthalmologist for referral to a psychiatrist. It should be emphasized that all of these patients with intractable blepharospasm need tranquilizers ; some of them have been photophobic cripples for years and some need help and counsel about a stressful situation at home or work. COMMENT
Decreasing the power of the overactive orbicularis muscle by surgical extirpation of part of the nerve supply to the muscle has now been performed in 14 patients. All have been helped, some more than others. Three who required reoperation have improved with the additional surgery. 903 South 21st Street.
Fig. 4 (Callahan). Removal of preseptal orbicularis muscle and tucking of inferior orbital septum.
( A ) An incision is made parallel to and about 5 to 7 mm from the lower lid margin. The medial third is not disturbed, permitting the medial part of the orbicularis to assist in conducting the tear fluid through the lacrimal drainage system. (B) The profile illustration shows how some of the preseptile orbicularis muscle should be removed and how the tucking suture should be placed. The needle is directed through the skin toward the septum below the tarsus, then directed through the septum. To make the tuck engage the tarsus below, the needle is passed through the septum below and then through the lower lid margin. (C) After excision of the orbicularis with further removal of facial nerve branches, the skin sutures are inserted and tied.
REFERENCES
Callahan, A.: Blepharospasm with resection of part of orbicularis nerve supply: Correction of intractable cases. Arch. Ophth., 70:508-511 (Oct.) 1963. Henderson, J. W. : Essential blepharospasm. Tr. Am. Ophth. S o c , 54 :453. 1956. lones, L. T., Reeh, M. ]., and Tsujimura, J. K. : Senile entropion. Am. J. Ophth., 55:463-469 (Mar.) 1963. Reeh, M. : Treatment of Lid and Epibulbar Tumors. Springfield, 111., Thomas, 1963.
A. E. MAUMENEE
ing. Thus, they are carrying basic research activities into patient care. It is planned that, when appropriate persons become available either through our residency training program or from other institutions, we will continue to add to our clinical faculty until the major fields of interest in clinical ophthalmology are covered. Persons in this category will see a limited number of patients, usually those referred for consultation, and will participate in the teaching program of the house officers and medical students, and will maintain an active interest in investigative work. The attending staff of the Institute will be restricted to those ophthalmologists who have proven themselves to be capable physicians and who have demonstrated an interest in teaching and research. No specific affiliations of the Institute with other eye clinics, services or hospitals are planned at the present time. However, we will continue to assist in the teaching program of local eye services, and will maintain and strengthen our relations with the Baltimore City Hospital
and the Veterans Hospital. If other services become available in the future with which it will be mutually advantageous for the Wilmer Institute to become closely affiliated, these arrangements will be carefully considered. Thus, the future plans for the Wilmer Institute do not hold major departures from the past. The new facilities and those already available in the Wilmer Institue will serve to house the modern, complicated instruments for research, and the teams of workers needed to carry out the investigative activities. The purposes of the Institute will be as they have been in the past : to train the best clinicians that we are capable of producing ; to instill in these persons a scientific approach and an interest in investigation ; to offer the best possible patient care; to produce excellence rather than volume in laboratory investigation ; and constantly to transform knowledge acquired in the laboratory into improved care for patients. The Johns Hopkins Hospital (5).
SURGICAL CORRECTION O F INTRACTABLE BLEPHAROSPASM TECHNICAL IMPROVEMENTS ALSTON CALLAHAN,
M.D.
Birmingham, Alabama
Since the publication in October, 1963, of an operation to lessen the contractile force of the orbicularis muscle in severe intractable blepharospasm, my experience has increased with three recurrences, seven more patients referred with this condition, and one sent for this operation who did not need it. Lessons learned from these patients and further operative procedures devised for some of the more resistant cases seem to justify publication of this additional information. Also, I have now read John Warren Henderson's illuminating report on the clinical
course of 135 patients with "essential blepharospasm" (meaning idiopathic blepharospasm). He believes that an organic basis for essential blepharospasm exists in the brain somewhere higher in the course of neuronal synapses than the facial nucleus in the pons. Henderson found that injection of alcohol into the facial nerve was not justified by the results. He did not find excision of a portion of the orbicularis muscle satisfactory and the most effective relief of symptoms among the patients he personally treated was achieved by resecting the main trunk of the facial nerve distal to the stylo-
INTRACTABLE BLEPHAROSPASM
789
Fig. 1 (Callahan). The facial nerve supply to the left orbicularis muscle. The motor nerve supply for the orbicularis muscle extends from the temperofacial division of the facial nerve. This division is made up primarily of the temporal, upper and lower zygomatic branches which lie in the submuscular fascia and interlay with each other. The temporal and upper zygomatic branches supply the muscles of the eyebrow in the upper half of the medial canthus. The lower zygomatic supplies the lower part of the orbicularis in the lower half of the medial canthus. The lateral part of the orbicularis is supplied by both zygomatic branches. mastoid foramen, but he recommends this only for severe blepharospasm associated with extensive spasms of other muscles of the face innervated by the facial nerve. It is easy to miss the diagnosis because the patient usually says, " I can't see," focusing attention on the eyes. If he would say, " I can't hold my eyelids open," the condition would be recognized immediately. Lester T . Jones' dissections of the anatomy and considerations of the physiology of the lid comprise the first section of the recently published Tumors of the Adnexa by Merrill Reeh. H i s study of the facial nerve supply to the orbicularis muscle furnished the information for F i g u r e 1 ; it shows how the nerve extends deep into the fascia and is comprised of a network of branches and anastomoses and rebranches which enter the muscle from behind. I n the operation, the branches are not identified, but the lateral band of the orbicularis muscle is resected and the resection is extended along an area higher than the eyebrow, and down in the cheek tangent to the orbicularis (fig. 2 ) .
T h e danger of complete facial paralysis is avoided by not extending the dissection and resection back toward the ear. If the frontal is also contracts as part of the blepharospasm, as evidenced by a Z-shaped kink over the corrugator, an incision should be made through the medial third of the brow and the attachment of the corrugator to the skull should be divided. The three patients who developed recurrences after being initially helped by this operation stated that they found it difficult to elevate their lids. Examination showed that, although the orbicularis muscles were adequately weakened, senile ptosis had developed, perhaps increased by the overriding strength of the orbicularis muscles which had existed for months or years. F o r this condition, as for ordinary cases of senile ptosis, the levator muscles are shortened by tucking (fig. 3 ) . Another of the patients, whose uncontrollable squeezing of the orbicularis recurred, found he could not read when he held the reading material in the normal position be-
ALSTON CALLAHAN one developed by Lester T. Jones and his co-workers for the correction of senile entropion (fig. 4 ) . It was mentioned that one patient was referred for this operation without proper indications. She said that she could not keep her eyes open and that she could not read and that she had to hold her eyes open with her fingers. She had vision without correc-
Fig. 2 (Callahan). Resection of facial nerve supply to orbicularis muscle. About 10 cc. of lidocaine (Xylocaine®*) mixed with hyaluronidase (Wydase®*) are injected along the posterior lateral border of the orbicularis muscle approximately 2.5 cm posterior to the lateral canthus. A curvilinear incision is made in the area of injection and the posterior lateral border of the orbicularis is exposed. A sector of the muscle, about 10-mm wide and 40 to 50-mm long around the lateral curve, is excised, removing the muscle and deep fascia until the periosteum is cleared. For extremely severe blepharospasm, a wider and longer orbicularis section can be removed, as shown by the dotted angles. * Astra Pharmaceutical Products, Inc., Worcester 6, Massachusetts. * Wyeth Laboratories, Philadelphia.
cause the margin of the lower lids rose higher than the level of the pupils. A functional and anatomic change of the lower lid noted in some of these patients is atrophy of the inferior orbital septum ; and the pretarsal and preseptal portions of the orbicularis muscle over a period of time had stretched the lid to make it rise too high. T o strengthen and shorten the inferior orbital septum and correct this part of the intractable blepharospasm, a part of the preseptal orbicularis is resected and the septum is tucked in, an operation modified from the
Fig. 3 (Callahan). Tucking of the levator palpebrae superioris. (A) Through a skin incision at the upper tarsal border, the orbicularis fibers are separated and the levator and Mueller's muscles and tendons are exposed; mattress sutures of gut (chromic 4-0) are inserted in the levator for an appropriate distance above the tarsus and then brought through the tendon at the upper range of the tarsus. (B) As these sutures are tied, the effectiveness of the levator is increased and the patient is able to elevate his lids higher.
INTRACTABLE BLEPHAROSPASM
791
tion of 20/20 in each eye and, when seen on three successive days, her eyes remained open, with a normal blink reflex which did not set off an orbicularis clamplike contraction. What her psychologic trauma or motivation was is not known. She was sent back to the referring ophthalmologist for referral to a psychiatrist. It should be emphasized that all of these patients with intractable blepharospasm need tranquilizers ; some of them have been photophobic cripples for years and some need help and counsel about a stressful situation at home or work. COMMENT
Decreasing the power of the overactive orbicularis muscle by surgical extirpation of part of the nerve supply to the muscle has now been performed in 14 patients. All have been helped, some more than others. Three who required reoperation have improved with the additional surgery. 903 South 21st Street.
Fig. 4 (Callahan). Removal of preseptal orbicularis muscle and tucking of inferior orbital septum.
( A ) An incision is made parallel to and about 5 to 7 mm from the lower lid margin. The medial third is not disturbed, permitting the medial part of the orbicularis to assist in conducting the tear fluid through the lacrimal drainage system. (B) The profile illustration shows how some of the preseptile orbicularis muscle should be removed and how the tucking suture should be placed. The needle is directed through the skin toward the septum below the tarsus, then directed through the septum. To make the tuck engage the tarsus below, the needle is passed through the septum below and then through the lower lid margin. (C) After excision of the orbicularis with further removal of facial nerve branches, the skin sutures are inserted and tied.
REFERENCES
Callahan, A.: Blepharospasm with resection of part of orbicularis nerve supply: Correction of intractable cases. Arch. Ophth., 70:508-511 (Oct.) 1963. Henderson, J. W. : Essential blepharospasm. Tr. Am. Ophth. S o c , 54 :453. 1956. lones, L. T., Reeh, M. ]., and Tsujimura, J. K. : Senile entropion. Am. J. Ophth., 55:463-469 (Mar.) 1963. Reeh, M. : Treatment of Lid and Epibulbar Tumors. Springfield, 111., Thomas, 1963.