BLEPHAROSPASM AND BOTULINUM TOXIN

► 1978 Dr. Alan Scott begins human trial of “oculinum toxin” for strabismus, hemifacial spasm, and blepharospasm

► 1989 FDA approves Botox for blepharospasm

► 2000 FDA approves Myoblock (type B) for cervicle dystonia

► 2009 FDA approves Dysport for cervical dystonia

► 2010 FDA approves Xeomin for cervical dystonia and blepharospasm not suggest “that we can’t or we shouldn’t use the other toxins.” Most insurance coverage guidelines, “Medicare, for instance, really treats all four toxins as equivalent” in terms of treatment but not in terms of dose. Often, insurances are impacted due to the financial side of the medications.

Botulinum toxin is essentially the treatment of choice for blepharospasm, and based upon the data, it seems to lead to “a far higher response rate…by a second or third round of treating someone: 90% or 90+% of individuals are going to have seen a marked improvement of 70% or better in their blepharospasm symptoms.” In contrast, oral medications yield “maybe 25% or so response rates.” scissors. It just clips whatever protein it has been designed to clip.” He used the analogy of a lawn mower just clipping grass with the reminder that the grass will grow back.

Samanta explained, “The idea behind botulinum toxin is trying to dial down the signal coming into that muscle.” He reminded the audience that the goal is not to turn off the nerve signals completely but rather to attempt to bring them within a range of normal functioning. The effects are temporary.

“Typically, the peak or the full blockade of a treatment is going to be reached at about 15 days,” rather than instantly. Then there is a period of a plateau. Over the next 12 weeks approximately, there is a gradual decline. Towards the end of that time, it is common to experience a gradual return of symptoms. Samanta said, “typically the duration of the benefit is somewhere between 12 and 14 weeks.” He continued to remind us that patients vary in the time they experience relief, likely due to metabolism rather than technique.

He further reminded us that although botulinum toxins are the treatment of choice, “every treatment has the potential for some adverse effects.” The most common ones noted are drooping eyelids (ptosis), dry eyes (likely under-reported), and double vision. Fortunately, these side effects are not permanent; both the injection sites and dosages can be adjusted with future injections. He reminded the audience that patient feedback is vital in aiding the physician in both increasing effectiveness and reducing adverse sideeffects.

In efforts to lower the chances of reduced effectiveness, he stressed the importance of not seeking booster treatments, or even cosmetic Botox treatments in the region between treatments as this can impact antibodies. If other injections are introduced, it is important to share that information with your physician.

In efforts to lower the chances of reduced effectiveness, he stressed the importance of not seeking booster treatments, or even cosmetic Botox treatments in the region between treatments as this can impact antibodies.

Of the four toxins, three of them are based on Type A botulinum toxin; Myobloc is based upon Type B. All of them have slightly different properties from a biochemical standpoint, creating differences in the way they are stored, reconstituted, the unit potency, and the recommended dosage ranges.

The toxins indirectly act on the voluntary muscles as they actually target the motor nerve endings, and attack the active part of the protein. These nerve endings then emit a reduced signal to the muscle. “It [botulinum toxin] goes into the nerve endings… and it’s like a pair of

In closing, Dr. Samanta stressed the importance of the following for successful results with botulinum toxin treatments:

• Injection sites are important.

• Physician’s experience matters.

• Starting low and gradually increasing doses is advised.

• Patient Feedback, especially in the results and side-effects experienced, are very important to communicate with your treating physician.

• Cosmetic Botox is still Botox. Having it performed between treatments can actually cause you to experience a build-up of resistance with reduced treatment effectiveness.

* Research partially funded by BEBRF