Pharmacologic Therapy

Injection of onabotulinumtoxinA (BOTOX; Allergan, Inc, Irvine, CA) into the pretarsal portion of the orbicularis oculi (OO) may be beneficial in individuals with apraxia of lid opening (ALO) associated with blepharospasm. It may also benefit those in whom ALO is due to pretarsal OO motor activity persistence, but not those in whom ALO is due to involuntary levator palpebrae inhibition (ILPI).^{[43, 44]}Patients who benefit from onabotulinumtoxinA injection should be observed every 2-3 months; repeat injections may be required.

Levodopa (benserazide 25 mg plus levodopa 100 mg; carbidopa 50 mg plus levodopa 200 mg) was reported to improve the symptoms of ALO in a patient with progressive supranuclear palsy in whom electromyography (EMG) confirmed that the ALO resulted from involuntary levator palpebrae inhibition (ILPI).^[45]Levodopa has also been reported to improve ALO symptoms in patients with Parkinson disease.^{[27, 46]}

In isolated individuals, the symptoms of ALO have been reported to improve with the use of sodium valproate^[47]and the anticholinergic agent trihexyphenidyl.^[48]

Frontalis Suspension and Myectomy

Patients with ALO may benefit from frontalis suspension.^{[49, 50]}In this procedure, the contraction of the frontalis elevates the eyelids. Orbicularis oculi (OO) resection may be carried out in combination with frontalis suspension if essential blepharospasm is present.^{[49, 51]}

Levator palpebrae superioris (LPS) aponeurosis reinsertion may be necessary in some individuals. Disinsertion may result from manual traction on the lids or the repeated OO contraction.

Medication

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Media Gallery

Diagram of the possible central pathways involved in the generation of inhibitory responses of the levator palpebrae superioris muscle. Caudal central nucleus (CCN), central caudal subdivision of the oculomotor (III) nucleus.
A man with apraxia of lid opening is unable to open his lids at will. Eye movements were full. Attempted eye opening resulted in frontalis muscle contraction, backward thrusting of the head, and pretarsal orbicularis oculi activity. Spontaneous reflex blinking was normal. The lids remained open following manual elevation.

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Apraxia of Lid Opening Treatment & Management

Pharmacologic Therapy

Frontalis Suspension and Myectomy

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