Ann Rehabil Med.  2015 Apr;39(2):303-307. 10.5535/arm.2015.39.2.303.

Simultaneous Loss of Bilateral Voluntary Eyelid Opening and Sustained Winking Response Following Bilateral Posterior Cerebral Artery Infarction

• Kim JY
• Kim YW
• Kim HS

• KMID: 2273053
• DOI: http://doi.org/10.5535/arm.2015.39.2.303

Abstract

Spontaneous opening and closing of both eyes usually occurs in the normal awake state, unless a deliberate and voluntary attempt is made to open only one eye. We present a rare case of a male patient who was unable to open both eyes simultaneously after bilateral posterior cerebral artery infarction. He was able to close both eyes voluntarily. However, he was unable to keep both eyes open simultaneously and either the right or left eye remained closed. Upon a verbal command to open both eyes, the opened eye closed and the contralateral eye opened. When the closed eye was forced open, the opened eye closed. We thus presented a case of right-left dissociation of voluntary eyelid opening following bilateral posterior cerebral artery infarction, which was treated with botulinum toxin type A injection. Differential diagnosis to other movement disorders of the eyelids was discussed.

Keyword

Eyelids; Botulinum toxins; Posterior cerebral artery; Blinking

MeSH Terms

Blinking*
Botulinum Toxins
Botulinum Toxins, Type A
Diagnosis, Differential
Eyelids*
Humans
Infarction, Posterior Cerebral Artery*
Male
Movement Disorders
Posterior Cerebral Artery
Botulinum Toxins
Botulinum Toxins, Type A

Figure

• 

  Fig. 1 Diffusion-weighted magnetic resonance image findings. Acute infarction at the level of pons, mid brain, bilateral cerebellum, bilateral thalamus and left visual cortex supplied by the basilar and posterior cerebellar arteries were evident.

• 

  Fig. 2 (A) Before botulinum toxin type A injection, the patient showed a winking response, and was unable to open both eyes simultaneously. (B) After injection of 30U botulinum toxin type A into the right orbicularis oculi muscle, simultaneous opening and closing of both eyes was possible.

• 

  Fig. 3 (A, B) Blink reflex study showed normal findings at both sides.

Reference

1. Cruz AA, Garcia DM, Pinto CT, Cechetti SP. Spontaneous eyeblink activity. Ocul Surf. 2011; 9:29–41. PMID: 21338567.

2. van Koningsbruggen MG, Peelen MV, Davies E, Rafal RD. Neural control of voluntary eye closure: a case study and an fMRI investigation of blinking and winking. Behav Neurol. 2012; 25:103–109. PMID: 22530264.

3. Esteban A, Traba A, Prieto J. Eyelid movements in health and disease. The supranuclear impairment of the palpebral motility. Neurophysiol Clin. 2004; 34:3–15. PMID: 15030796.

4. Schmidtke K, Büttner-Ennever JA. Nervous control of eyelid function: a review of clinical, experimental and pathological data. Brain. 1992; 115 Pt 1:227–247. PMID: 1559156.

5. Esteban A, Gimenez-Roldan S. Involuntary closure of eyelids in parkinsonism: electrophysiological evidence for prolonged inhibition of the levator palpebrae muscles. J Neurol Sci. 1988; 85:333–345. PMID: 3210029.

6. Defazio G, Livrea P, Lamberti P, De Salvia R, Laddomada G, Giorelli M, et al. Isolated so-called apraxia of eyelid opening: report of 10 cases and a review of the literature. Eur Neurol. 1998; 39:204–210. PMID: 9635470.

7. Nashold BS Jr, Gills JP, Wilson WP. Ocular signs of brain stimulation in the human. Confin Neurol. 1967; 29:169–174. PMID: 4232575.

8. Aramideh M, Ongerboer de, Koelman JH, Speelman JD. Motor persistence of orbicularis oculi muscle in eyelid-opening disorders. Neurology. 1995; 45:897–902. PMID: 7746403.

9. Keam SJ, Muir VJ, Deeks ED. Botulinum toxin A (Dysport®): in dystonias and focal spasticity. Drugs. 2011; 71:1043–1058. PMID: 21668041.