Treatment of blepharospasm with apraclonidine

Objective To describe improvement in blepharospasm with apraclonidine. Background Blepharospasm is a focal dystonia involving chiefly the orbicularis oculi and periocular muscles resulting in involuntary sustained eyelid closure. Botulinum toxin injection is the mainstay of treatment with meaningful improvement in over 85% of patients, but the effects often wear off within 3–4 months. Apraclonidine is an alpha-2 adrenergic receptor agonist, which causes contraction of superior tarsal (Müller) muscle which may improve blepharospasm-related eyelid closure. We propose that apraclonidine may be a useful short-term treatment in patients with blepharospasm, particularly during wearing off from botulinum toxin injection. Methods Patients who had pre-mature wearing off of botulinum injection effect were evaluated before and after the administration of 2 drops of apraclonidine 0.5%–1% solution to each eye. Subjective patient impressions and examiner's impression of symptoms pre and post-apraclonidine administration were recorded. A blinded rater evaluated the videos and provided an independent assessment of the severity of symptoms pre- and post-administration, using a 0–4 scale. Results Our study included 7 patients (4 male) with a mean age of 61 years and mean duration of blepharospasm of 3.6 years. There was a subjective, albeit transient (about 2–4 h) improvement in blepharospasm reported by all patients and by the examiner. The mean severity scores, based on blinded video ratings, showed a reduction from of 3.4 pre-administration to 2.3 post-administration of apraclonidine (p < 0.025). No adverse effects were noted. Conclusions Apraclonidine is a potentially useful medication for short term management of blepharospasm symptoms while awaiting botulinum toxin injection.