Case Report
Trifluperazine Induced Blepharospasm – A Missed Diagnosis
Sood T1*, Tomar M2, Sharma A2 and Ravinder G3
1Department of Ophthalmology, Civil Hospital Sarkaghat, India
2Department of Ophthalmology, Indira Gandhi Medical College, India
3Department of Dermatology, Zonal Hospital Bilaspur, India
*Corresponding author: Tarun Sood, Department of Ophthalmology, Civil Hospital Sarkaghat, Himachal Pardesh, India
Published: 24 Aug 2016
Cite this article as: Sood T, Tomar M, Sharma A,
Ravinder G. Trifluperazine Induced
Blepharospasm – A Missed Diagnosis.
Ann Clin Case Rep. 2016; 1: 1092.
Abstract
Tardive dystonia is a class of “tardive” movement disorder caused by antipsychotics and is specified by reflex muscle contraction, which may be tonic, spasmodic, patterned, or repetitive. This neurological disorder most commonly occurs as the repercussion of long-term or high-dose use of antipsychotic drugs. Tardive dyskinesia uncommonly inculpates the muscles of eye closure. Blepharospasm is a kind of focal tardive dystonia distinguished by persistent intermittent or persistent closure of the eyelids. Blepharospasm is an uncommon, persistently disabling medical condition rendering patient functionally blind and occupationally handicapped .We hereby tend to report a case of trifluoperazine induced tardive blepharospasm.
Case Presentation
A 46-year male patient reported to eye opd with complaint of progressive difficulty in opening
his eyes for last two years .On examination he was unable to open his eyes voluntarily, sometimes
thrusting his head backwards or rubbing his brow with his fingers during these episodes. Past
and family history revealed no psychiatric or neurological illness. No past history of any other
psychiatric/medical/surgical illness could be elicited.
On specifically asking about medication history, he gave history of trifluoperazine intake.
Patient was diagnosed with schizophreniform disorder 3 years back and was on treatment since
then. Initially, he was started with 5mg trifluoperazine in twice daily dosage which had to be
increased to (15mg/day) within a month. He was kept on this maintenance dosage for 2 years. While
being treated with trifluoperazine after 1 year patient developed frequent and forceful blinking of
his eyelids. He would blink his eyes about 35-40 times in a minute when exacerbated by bright light.
During this course he consulted many doctors for blepharospasm but no cause could be
established.
Vitals were found stable on examination. No other neurological deficit could be diagnosed
other than the abnormal movements. Blood biochemistry, complete blood picture, ECG, EEG,
and brain imaging were essentially normal. The patient had no prior personal or family history of
blepharospasm or any other movement disorders.
Visual Acuity (with correction) was 20/25 Right eye (OD) and 20/20 Left eye (OS) and
Extraocular Motility was Full in both eyes (OU). B/L/ Pupils were found reacting well to light OS,
no RAPD OU. Intraocular Pressure was 15 mmHg OU. Confrontation Visual Fields were Full OU.
On External Examination presence of bilateral brow ptosis was noticed. Frequent spasms of
the orbicularis oculi muscles, procerus, corrugators were present bilaterally causing forcible eyelid
closure. Slit Lamp Examination revealed no abnormality .Dilated Funduscopic Examination
revealed Normal disc, macula, vessels, and periphery OU.
Discussion
Blepharospasm is classified as a type of focal dystonia and has been reported to
occur with atypical antipsychotics. Tardive syndrome (TS) is a group of hyperkinetic or
hypokinetic movement disorders and sensory symptoms sharing the same pathophysiological
basis. The etiological theories and treatment strategies have been elucidated recently
[1,2]. This report presents a case of trifluoperazine-induced tardive dystonia.
Trifluoperazine is a phenothiazine antipsychotic with high affinity
for D2 receptors relative to D1 receptors [3]. It has lesser propensity
to induce seizures than other antipsychotics and therefore it is
considered a “good choice” in treatment of comorbid schizophrenia
and epilepsy [4]. Trifluoperazine results in a variety of adverse
reactions including sedation and weight gain, but t o a lesser degree
other antipsychotics [5,6]. Other adverse effects include postural
hypotension, constipation, parkinsonism, priapism, and sexual
dysfunction [7,8]. Trifluoperazine has been known for its high
propensity to cause extrapyramidal side effects, such as tardive
dyskinesia and akathisia [9,10].
By definition, tardive dyskinesia is a result of drug therapy.
Tardive dyskinesia is a movement disorder resulting from taking
certain drugs, distinctively a class of drugs called neuroleptics. These
drugs effect the chemicals in the brain. One of the chemicals affected
is dopamine, which has a pivotal character in control of movement.
The extended use of neuroleptics leads to some aadaption in the
motor system that steers production of involuntary movement. Since
these movements are produced as late effect of taking these drugs, the
dyskinesia is called tardive, which means late. Once these movements
occur, they can be quite long-lasting and possibly permanent. Tardive
dyskinesias can affect any muscle in the body, but they very commonly
affect cranial nerve muscles. The muscles affected commonly are
tongue, the jaw closing muscles, and the muscles around the mouth,
but eyelid closing muscles can also be affected. When eyelid closing
muscles are affected, there can be blinking or sustained closure of
the eyelids, which could mimick blepharospasm. Movements of the
tongue and lips are particularly emine Tardive Blepharospasm is
worse in stress, fatigue, bright lights, watching television or driving,
and social interactions while Sleep, relaxation, walking, talking and
other "tricks" alleviate symptoms temporarily.
The early symptoms of blepharospasm include increased blink
rate (77%), eyelid spasms (66%), eye irritation (55%), midfacial or
lower facial spasm (59%), brow spasm (24%), and eyelid tic (22%). nt
in tardive dyskinesia. These movements can also occur in rhythmic
repetitive trains.
Because both blepharospasm and tardive dyskinesia can cause
blinking or sustained closure of the eyelids, their appearance can be
similar. However, tardive dyskinesia would only infrequently involve
the muscles of eye closure. Therefore, unless the focal dystonia in the
patient with blepharospasm has spread to involve the rest of the face,
it ordinarily would not be difficult on clinical grounds to separate
patients with blepharospasm and tardive dyskinesia.Lastly, both blepharospasm and tardive dyskinesia are difficult
to treat. There is no systemic medication that works well for either
condition [11].
Conclusion
It is very important to consider possibility of tardive blepharospasm in a patient on trifluoperazine therapy. Patient must be referred to an ophthalmologist to look for possibility of tardive blepharospasm in case suspicion arises. Attention must be paid to specific cause and appropriate management because blepharospasm interferes with performance and enjoyment of day to day activities.
References
- Waln O, Jankovic J. An update on tardive dyskinesia: From phenomenology to treatment. Tremor Other Hyperkinet Mov (N Y). 2013; 3.
- Bhidayasiri R, Fahn S, Weiner WJ, Gronseth GS, Sullivan KL, Zesiewicz TA, et al. Evidence-based guideline: Treatment of tardive syndromes: Report of the Guideline Development Subcommittee of the American Academy of Neurology. 2013; 81: 463-469.
- Owens DC. Meet the relatives: a reintroduction to the clinical pharmacology of “typical” antipsychotics. Advances in Psychiatric Treatment. 2012; 18 337–350.
- Hedges D, Jeppson K, Whitehead P. Antipsychotic medication and seizures: a review. Drugs of Today. 2003; 39: 551–557.
- Marques LDO, Soares B, Silva de Lima M. Trifluoperazine for schizophrenia. Cochrane Database of Systematic Reviews. 2004; 1: CD003545.
- Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th edition. chapter 7. London, UK: Informa Healthcare; 2009.
- Bashford G, Bradd P. Drug-induced Parkinsonism associated with dysphagia and aspiration: a brief report.Journal of Geriatric Psychiatry and Neurology. 1996; 9: 133–135.
- Barnes TR, Katona CL. Susceptibility to drug-induced hypotension in post-partum psychosis.International Clinical Psychopharmacology. 1986; 1: 74–76.
- Sachdev P. Tardive blepharospasm. Movement Disorders. 1998; 13: 947– 951.
- Chouinard G, Boisvert D, Bradwejn J. Tardive dyskinesia in a nonpsychiatric patient due to short-term use of a neuroleptic/anticholinergic combination drug. Canadian Medical Association Journal. 1982; 126: 821–827.
- Benign Essential Blepharospasm Research Foundation Newsletter. 2012; 31.