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Involuntary eyelid closure after STN-DBS: evidence for different pathophysiological entities
  1. Daniel Weiss1,
  2. Tobias Wächter1,
  3. Sorin Breit1,
  4. Simon N Jacob1,
  5. Jörn K Pomper1,
  6. Friedrich Asmus1,
  7. Josep Valls-Solé2,
  8. Christian Plewnia3,
  9. Thomas Gasser1,
  10. Alireza Gharabaghi4,
  11. Rejko Krüger1
  1. 1Center of Neurology, Hertie Institute for Clinical Brain Research, and German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
  2. 2Neurology Department, Hospital Clinic, IDIBAPS, Facultad de Medicina, Barcelona, Spain
  3. 3Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
  4. 4Department of Neurosurgery, University of Tübingen, Tübingen, Germany
  1. Correspondence to Dr Rejko Krüger, BrainStimNet Tübingen, Center of Neurology, Hertie Institute for Clinical Brain Research, University of Tübingen, Hoppe-Seyler-Str. 3, Tübingen, D-72076, Germany; rejko.krueger{at}


Objective Involuntary eyelid closure (IEC) may occur after deep brain stimulation of the subthalamic nucleus (STN-DBS) in Parkinson's disease (PD) and is often categorised as apraxia of lid opening (ALO), albeit the appropriateness of this term is under debate. To gain insight into the hitherto undefined pathophysiology of IEC after STN-DBS, we performed a comprehensive clinical and electrophysiological characterisation of lid function in a total of six PD patients.

Methods The study was carried out in six PD patients who developed IEC after STN-DBS. They underwent neurological examination and electromyography recording of activity in the orbicularis oculi muscle (OO) upon varying stimulation patterns. Intraoperative studies were performed in one patient.

Results Increasing STN-DBS intensity induced IEC in four patients, whereas it improved the condition in two. Needle EMG showed tonic hyperactivity of the OO in STN-DBS induced IEC, while variable patterns of OO activity (irregular and tonic) were seen in patients with STN-DBS-relieved IEC. Intraoperative analysis in one patient showed evidence for IEC being induced by activation of corticobulbar fibres.

Conclusions We identified two groups of IEC after STN-DBS based on clinical and EMG patterns: (1) STN-DBS induced IEC associated with tonic OO overactivity and (2) STN-DBS relieved IEC presenting with variable EMG patterns. Our findings provide relevant information on pathophysiology of STN-DBS related IEC and implications for its therapeutic management.

  • Deep brain stimulation (DBS)
  • subthalamic nucleus (STN)
  • blepharospasm
  • apraxia of lid opening (ALO)
  • Parkinson's disease (PD)
  • clinical neurology
  • electrical stimulation
  • EMG
  • movement disorders

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  • Funding DW was supported by a research grant from Medtronic. JKP was supported by the Hertie-Foundation. AG has been funded by DFG GH 94/2-1, BMBF 16SV3783 and ERC 227632 grants. RK is supported by grants of the DFG (KR2119/3-1) and BMBF (01GS01834).

  • Competing interests FA has received speakers' honoraria and travel grants from Ipsen Pharma, Allergan and Merz Pharmaceuticals. TG has received speakers' honoraria from Novartis, Merck-Serono, Schwarz Pharma, Boehringer Ingelheim and Valeant Pharma, and research grants from Helmholtz Alliance for Health in an Ageing Society (HELMA).

  • Patient constent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.