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Meta-Analysis
. 2020 Nov 19;11(11):CD004900.
doi: 10.1002/14651858.CD004900.pub3.

Botulinum toxin type A therapy for blepharospasm

Gonçalo S Duarte #  1   2 , Filipe B Rodrigues #  1   2 , Raquel E Marques  2   3 , Mafalda Castelão  1   2 , Joaquim Ferreira  1   2 , Cristina Sampaio  4 , Austen P Moore  5 , João Costa  1   2
Affiliations
Meta-Analysis

Botulinum toxin type A therapy for blepharospasm

Gonçalo S Duarte et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of a Cochrane Review first published in 2005. Blepharospasm is the second most common form of focal dystonia. It is a disabling disorder, characterised by chronic, intermittent or persistent, involuntary eyelid closure, due to spasmodic contractions of the orbicularis oculi muscles. Currently, botulinum toxin type A (BtA) is considered the first line of therapy for this condition.

Objectives: To compare the efficacy, safety, and tolerability of BtA versus placebo in people with blepharospasm.

Search methods: We searched Cochrane Movement Disorders' Trials Register, CENTRAL, MEDLINE, Embase, reference lists of included articles, and conference proceedings. We ran all elements of the search, with no language restrictions, in July 2020.

Selection criteria: Double-blind, parallel, randomised, placebo-controlled trials (RCTs) of BtA versus placebo in adults with blepharospasm.

Data collection and analysis: Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus, or by consulting a third review author. We performed meta-analyses using a random-effects model, for the comparison of BtA versus placebo, to estimate pooled effects and corresponding 95% confidence intervals (95% CI). We did not carry out any prespecified subgroup analyses. The primary efficacy outcome was improvement on any validated symptomatic rating scale. The primary safety outcome was the proportion of participants with any adverse event.

Main results: We included three RCTs, assessed at low to moderate overall risk of bias, which randomised 313 participants with blepharospasm. Two studies excluded participants with poorer prior responses to BtA treatment, therefore, they included an enriched population with a higher probability of benefiting from this therapy. All trials were industry-funded. All RCTs evaluated the effect of a single BtA treatment session. BtA resulted in a moderate to large improvement in blepharospasm-specific severity, with a reduction of 0.93 points on the Jankovic Rating Scale (JRS) severity subscale at four to six weeks after injection (95% confidence interval (CI) 0.61 to 1.25; I² = 9%) compared to placebo. BtA was also resulted in a moderate to large improvement in blepharospasm-specific disability and blepharospasm-specific involuntary movements at four to six weeks after injection (disability: 0.69 JRS disability subscale points, 95% CI 0.18 to 1.19; I² = 74%; blepharospasm-specific involuntary movements: standardised mean difference (SMD) 0.79, 0.31 to 1.27; I² = 58%) compared to placebo. BtA did not show a risk of adverse events (risk ratio (RR) 1.18, 95% CI 0.87 to 1.60; I² = 0%). However, BtA increased the risk of vision complaints and eyelid ptosis (vision complaints: RR 5.73, 95% CI 1.79 to 18.36; I² = 51%; eyelid ptosis: RR 4.02, 95% CI 1.61 to 10.00; I² = 39%). There was no distinction between BtA and placebo in the number of participants who dropped out of the trial. A single trial estimated the duration of effects to be 10.6 weeks (range 6.1 to 19.1). We found no evidence supporting the existence of a clear dose-response relationship with BtA. We found no data reporting the impact of BtA on health-related quality of life, or the development of secondary non-responsiveness.

Authors' conclusions: We are moderately certain that a single BtA treatment resulted in a clinically relevant reduction of blepharospasm-specific severity and disability, and have low certainty that it is well tolerated, when compared with placebo. There is low-certainty evidence that people treated with BtA are not at an increased risk of developing adverse events, though BtA treatment likely increases the risk of visual complaints and eyelid ptosis. There are no data from RCTs evaluating the effectiveness and safety of repeated BtA injection cycles. There is no evidence from RCTs to allow us to draw definitive conclusions on the optimal treatment intervals and doses, or the impact on quality of life.

Trial registration: ClinicalTrials.gov NCT01896895.

PubMed Disclaimer

Conflict of interest statement

JC, JJF, and CS were investigators in clinical trials for the use of botulinum toxin A and B in dystonia, sponsored by Elan (manufacturer of botulinum toxin type B), Allergan (manufacturer of botulinum toxin type A), and Ipsen (manufacturer of botulinum toxin type A). Searching for studies, selection of studies, data extraction and analysis (including risk of bias), and GRADE assessment were performed by review authors (FBR, GSD, MC, REM) who were not trialists. JJF and CS were speakers in symposia promoted by Elan, Allergan, and Ipsen.

APM has received royalties from Ipsen for the use of the 'LIVEchart' scoring system for botulinum toxin treatment efficacy. In addition, he has received consulting fees from Ipsen, Merz (manufacturer of botulinum toxin type A), Eisai (manufacturer of botulinum toxin type B), and Allergan. The same companies have provided support for travel to meetings for studies or other purposes.

Figures

1
1
Flow diagram for study selection
2
2
'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
3
3
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
1.1
1.1. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 1: Blepharospasm‐specific severity
1.2
1.2. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 2: Blepharospasm‐specific disability
1.3
1.3. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 3: Adverse events
1.4
1.4. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 4: Vision complaints (diplopia, blurred vision, visual disturbance)
1.5
1.5. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 5: Eyelid ptosis
1.6
1.6. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 6: Increased lacrimation
1.7
1.7. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 7: Xerophthalmia
1.8
1.8. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 8: Frequency of blepharospasm‐specific involuntary movements
1.9
1.9. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 9: Subjective participant evaluation
1.10
1.10. Analysis
Comparison 1: Botulinum toxin type A (BtA) versus placebo, Outcome 10: Tolerability – dropouts
See this image and copyright information in PMC

Update of

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