I treat a lot of patients with blepharospasm in Denver with Botox and surgery. One of the most overlooked problems with blepharospasm is apraxia of eyelid opening. Apraxia of eyelid opening describes the problem that many blepharospasm patients suffer with it that are often missed. Essentially patients have trouble opening their eyes usually after an episode of spasm.

In Blepharospasm patients have problems opening their eyelids due to excessive “firing” of neurons stimulating eyelid closure. Apraxia of eyelid opening is when the neurons for opening the eyelid are unable to overcome the ones for closing the eyes. We are not 100% sure why patients with Blepharospasm commonly have eyelid apraxia issues. Classically, blepharospasm patients with apraxia of eyelid opening will have sustained spasm of eyelid closure which is then followed by a sustained inability to open the eye. Some patients have to manually open their eyelids. Others have to raise their eyebrows to try to get their eyes open. Many patients feel blinded by apraxia of eyelid opening. As one can imagine while driving or other serious activities, the inability to open ones eyes can be disabling. Most physicians are completely unaware of apraxia of eyelid opening and its treatment

In most patients without apraxia of eyelid opening, inability to close the eyes are caused by ptosis, dermatochalasis and brow ptosis. These are aging changes to the eyelid, eyelid muscle and eyebrow and are addressed by tightened the weakened eyelid muscles, removing excess eyelid skin and raising the eyebrows. Patients with apraxia of eyelid opening can also have these problems which can improve with treatment but most often this is not the problem.

What is the treatment of apraxia of eyelid opening?

1. Botox

2. Myectomy

3. Ptosis repair

4. Sling placement

Studies have shown in patients with apraxia of eyelid opening have simultaneous opening and closing of the eyelid muscles stimulated. As a result, the eyelid is paralyzed to move. The first goal of apraxia of eyelid opening treatment to stop the contracting closure muscles of the eyelid ie the orbicularis muscle.

This is often treated with Botox injections into the eyelid. When this happens the orbicularis muscle (Muscle for eyelid closing) is paralyzed. In over 85% of patients Botox is effective for Blepharospasm. In patients who have failure of Botox it is important to determine if the botox did not work or the patient has apraxia of eyelid opening. We test this in the office by examining orbicularis paralysis and seeing if the main problem is eyelid apraxia at that point.

If eyelid apraxia is the main problem, a myectomy is needed to remove the muscles that contract the eyelids closed. This is a surgery that is done through skin fold incisions to remove muscles that normally contract the eyelid shut. The procedure takes one hour and recovery is roughly two weeks. First we often do the upper eyelid muscle before doing the same procedure on the lower eyelid. Often the amount of botox needed after treatment is reduced and the eyes are more open. Their apraxia of eyelid opening improves as well. In the upper eyelids we often tighten or strengthen the levator muscle to open the eyelid as well.

If patients who have had an upper myectomy and botox are not fully treated we will then remove the eyelid closure muscles from the lower eyelid as well.

In a few patients, a sling is needed to raise the eyelids by connecting it to the eyebrow.

Apraxia of lid opening is challenging to treat but oculoplastic surgeons such as myself have a great algorithm to treat these patients to give them functional outcomes that improve their lives so they can function. It is unknown exactly why eyelid apraxia goes hand in hand with Blepharospasm. Specificially, blepharospasm patients who have “failed botox” should be evaluated for apraxia of eyelid opening to see if that is the problem that needs treatment.