A 50-year-old Caucasian female presents to your office with a six month history of periodic involuntary closure of her right eye. The closure is provoked by bright light or cigarette smoke. Her past medical history is significant for osteoarthritis of her left knee. She takes naproxen occasionally. The attempt to check the pupillary reaction induces prolonged closure of the right eye. Otherwise, the neurologic examination is normal. Which of the following is the next best step in the management of this patient?

Question

A 50-year-old Caucasian female presents to your office with a six month history of periodic involuntary closure of her right eye.  The closure is provoked by bright light or cigarette smoke.  Her past medical history is significant for osteoarthritis of her left knee.  She takes naproxen occasionally.  The attempt to check the pupillary reaction induces prolonged closure of the right eye.  Otherwise, the neurologic examination is normal.  Which of the following is the next best step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The clinical scenario described is suggestive of blepharospasm, which is a form of focal dystonia. The history of periodic involuntary eye closure that can be provoked by external stimuli (eg, bright light or irritants) is typical. Older women are particularly predisposed to this condition. A potential explanation is that dry eyes in postmenopausal women may serve as a trigger for blepharospasm. Botulinum toxin injections are the mainstay of treatment. They can be used for many years without any loss of efficacy or significant side effects. (Choices A, B, and D) Oral agents such as levodopa, trihexyphenidyl, and carbamazepine are employed in the treatment of more generalized forms of dystonia, and are marginally effective in patients with blepharospasm. (Choice E) Although reactive depression can be associated with blepharospasm, psychotherapy is not the treatment of choice in this case. Educational objective: Botulinum toxin injections are very effective and relatively safe in the treatment of patients with focal dystonia.

A 50-Year-Old Caucasian Female Presents to Your Office with a Six