BOTULINUM TOXIN TREATMENT OF APRAXIA OF EYELID OPENING IN PROGRESSIVESUPRANUCLEAR PALSY - REPORT OF 2 CASES

We report two patients, with postural instability and dystonic parkins onism whose adjunctive disabling feature was blindness due to an inabi lity to reopen the eyes after voluntary closure of the eyelids, as in apraxia of lid opening (ALO). Supranuclear downgaze paresis permitted the diagnosis of progressive supranuclear palsy (PSP) in one case. Ele ctromyographic studies showed a loss of normal reciprocal inhibition b etween the levator palpebrae and the pretarsal portion of the orbicula ris oculi, with a cocontraction of these two antagonist muscles. The e voked blink reflex, tested with the paired shock technique, showed enh anced recovery of R2 response. Botulinum toxin A injections directed t oward the junction of the preseptal and pretarsal parts of the palpebr al orbicularis oculi muscle improved eyelid motility in both patients. Successive static and dynamic balance training and development of com pensatory strategies for visual scanning deficits reduced gait imbalan ce, the number of falls, and the disability level as measured on the N orthwestern University Disability Scale. (C) 1997 by the American Cong ress of Rehabilitation Medicine and the American Academy of Physical M edicine and Rehabilitation.