Neuro-ophthalmology: Facial Spasm

Question 1

Describe essential blepharspasm (facial spasm)?

Answer 1

• Uncommon but distressing for px
• Presents in 50s
• F:M -> 3:1
• Progressive bilateral involuntary spasm of orbicularis oculi & upper facial muscles
  o Pxs will describe that suddenly their eyes shut and they couldn’t see or open their eyes –> VERY SCARY – could happen whilst someone is driving
• Cause unknown – likely to be mixture of genetic & environment
• Predisposing factors: reading, driving, stress, bright light
• Alleviated by: talking, walking, relaxing
• Brief contracture

Question 2

Describe facial hemispasm (facial spasm)?

Answer 2

• Just one half of face
• Unilateral
• Age: 40s to 50s
• Brief spasm of orbicularis oculi spreading along facial nerve
• Idiopathic most commonly (aberrant BVs compressing facial nerve) or due to irritation to nucleus of nerve (e.g. tumour, stroke, multiple sclerosis)
  o Cause needs to be investigated
• May occur several months/years after Bell’s palsy
  o Could be a complication of Bell’s Palsy
• Brief contracture

Question 3

Describe Bell’s Palsy

Answer 3

Often seen when the px tries to smile – the muscles are not contracting as they should to produce a smile
Abnormal side is his RHS of face
This is something that will be there for a while
* Paralysis of facial nerve (VII CN)
* Bell’s Palsy constitutes 72% of all facial palsy
* Especially between 15 & 45 yrs
* M = F -> except in pregnancy

Question 4

List the conditions in which Bell’s Palsy is more common and what is the cause of Bell’s Palsy?

Answer 4

• Pregnancy
• Diabetes
• HIV
  Cause:
• Unknown
• Sometimes associated w/:
  o Latent virus infection (HSV type 1, HZ)
  o Influenza
  o Respiratory tract infections
  o Depleted immune system
  o Stress

Question 5

What are the symptoms of Bell’s Palsy?

Answer 5

• Sharp pain in inner ear during onset of paralysis
• Some do not notice the facial palsy unless someone points it out or they try to speak
• Impaired or altered sense of taste
• Sensitivity to loud noises
• Difficult eating & speaking
• Distressing cosmetic change due to loss of muscle tone on one side of face
• Ocular exposure (because the eyes cannot shut properly) causes:
  o Redness
  o Discomfort
  o Pain
  o Photophobia – if corneal surface is damaged
  o Watering of eye – if corneal surface is damaged
   Epiphora: if eye cannot close & tears cannot be pumped away as usual – the tears can be left there & spill over onto cheek

Question 6

What are the signs of Bell’s Palsy?

Answer 6

• Eyebrow may drop slightly compared to other side
• Upper lid may retract & lower lid may sit lower – both eyelids open up the eye & eye may appear bigger (even though it is not)
• Rest of cheek & above mouth – loss of sulci & folds – corner of mout may drop
• Ocular Signs:
  o Unilateral facial weakness including orbicularis oculi – px won’t be able to blink completely
  o Incomplete blink leads to cornea drying – most of drying happens at small gap on bottom third of eye where eyelids meet each other
   Px may get dry eye symptoms – staining of cornea as result
  o Incomplete closure at night (lagophthalmos) causes corneal exposure – eyes never closing so cornea can get v dry
  o Loss of lacrimal pump mechanism produces pooling of tears in eye & epiphora (tears then fall on cheek)
  o Conjunctival hyperaemia, oedema, staining
  o Corneal desiccation ranges from mid superficial punctate erosions to frank ulceration – usually inferior – if erosions are left to get bigger

Question 7

What are the differential diagnosis for Bell’s Palsy?

Answer 7

• Other causes of facial nerve palsy:
  o Part of a stroke – cerebro-vascular accident w/ hemiplegia
  o Infection – e.g. otitis media, Lyme disease
  o Trauma – e.g. cranial fracture, facial laceration
  o Tumour – e.g acoustic neuroma: damage to nerve by tumour or secondary to surgical trauma
• Other causes of watering & inferior corneal exposure:
  o Ectropion
  o Entropion
• Other causes of lagophthalmos (eyes can’t close fully & completely):
  o Orbital – thyroid eye disease
  o Mechanical – cicatricial – look for lid scarring
  o Physiological – get someone who px lives with to check for full lid closure at night – some people’s eyes just don’t fully close

Question 8

What is the prognosis of Bell’s Palsy?

Answer 8

• Fair prognosis w/o treatment
• 82% recover normal function within 9 months
• Most improvement occurs within 3 weeks
  o If px has other eye complications e.g. dry eye, corneal ulceration – these would need dealt with & would recover differently
• In remaining 20-30%, px is left w/ a degree of permanent facial paralysis
  o Severe nerve damage is more likely to occur if px:
   Is over 60
   Had severe pain at onset
   Had complete rather than partial paralysis at onset
   Has DM or HBP
   Was pregnant at the time of onset
   If recovery had not begun after six weeks
• 7% are recurrent – w/ a 10yr average interval between attacks  useful for pxs to know what might happen in longer term

Question 9

What is the management of Bell’s Palsy?

Answer 9

• Contracture:
  o Shortening of facial muscles over time may make affected side of face appear to be slightly ‘lifted’ – less creases down that side of face
  o Affected eye may appear smaller than unaffected eye
  o Fold between outer edge of nostril & corner of mouth may seem deeper due to increased contraction of cheek muscles on that side
• Crocodile tears:
  o Affected eye waters involuntarily, particularly whilst eating due to faulty ‘re-wiring’ of nerves during recovery phase
• Synkinesis:
  o When intentionally trying to move one part of face, another part automatically moves – e.g. on smiling, eye on affected side automatically closes

Question 10

What are the CMGs regarding management of Bell’s Palsy?

Answer 10

• Tx by optom:
  o New cases & where there is loss of corneal sensation: 1st aid measures & emergency (same day) referral
  o Improved prognosis in moderate/severe cases of Bell’s palsy if treated w/ systemic corticosteroids within 72 hours of onset
   Useful to find out from px the time that this happened
  o NB: corneal ulceration due to exposure is potentially sight threatening & may justify emergency referral
  o Recovering & established cases: alleviation/palliation – tx of dry eye etc; no referral
   If cannot be managed easily, then: prescription of drugs; routine referral
  o Tape lids closed at night – to decrease risk of exposure
  o Sunglasses for photophobia & general protection
  o Artificial tears by day, unmedicated ointment at night – for dryness of eye
  o Therapeutic CL considered if unresponsive to frequent use of ocular lubricants
• Management by ophthalmologist:
  o Urgent medical tx for new cases w/ systemic steroid – especially if within 72hrs
  o Surgery for permanently unrecovered cases – e.g. altering position of eyelids so they can close