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We read with interest the study by Hall et al1 on health-related quality of life (HRQOL) in patients with benign essential blepharospasm (BEB) and hemifacial spasm (HFS). Hall and colleagues demonstrated that those with BEB experienced a greater reduction in a vision-targeted HRQOL and greater anxiety and depressive symptoms compared with patients with HFS.1 Their choice of HFS as a comparison group rather than healthy controls or controls with non-eye-related disease raises the question of whether their findings could be solely explained by the hypothesis that unilateral symptoms in HFS are better tolerated than the bilateral symptoms in BEB. Instead, the poorer HRQOL in BEB could reflect a referral bias to ophthalmology centers, as ophthalmologists may be seeing the more severe BEB cases compared with HFS. Although eyelid closure is the most common initial manifestation in HFS, the condition almost always involves the lower facial muscles, and the platysma muscles are also frequently affected. In our previous study of HRQOL measures in HFS,2 difficulty with speech and oral communication were among the many non-vision-related complications highlighted by patients with HFS. The patients with more severe HFS with such symptoms are more likely to be seen in a neurological or movement disorders service rather than in an ophthalmology referral center. Hence, unless Hall and colleagues are able to provide standardized assessment of the severity of BEB and HFS in their study, cautious interpretation of a direct comparison between these 2 conditions should be exercised. Correlation of the severity of disease with HRQOL measures and the timing of administration of the survey (during a period of maximal response or the wearing off of the effect of botulinum toxin), which is an important confounding factor, were also not mentioned.
In addition, we would like to highlight that patients with HFS do experience significant deterioration of HRQOL. We previously developed 2 HFS-specific HRQOL scales (HFS-30 and HFS-7), and the HFS-7 scale closely correlated with the emotional and social domains of a widely used generic HRQOL scale, the 36-Item Short-Form Health Survey.2 - 3 Many vision-related activities such as reading, watching television, and driving had significant impacts on HRQOL measures as perceived by patients with HFS, and botulinum toxin treatment improved these symptoms.2 - 3 Separately, with a face-to-face evaluation, we demonstrated that depressive disorder was present in about 20% of patients with HFS; this correlated with the clinical severity of the disease.4
Although Hall and colleagues showed that patients with BEB appear to do worse with vision-targeted HRQOL compared with patients with HFS in an ophthalmology referral setting, it is important to recognize that ophthalmological, neurological, and psychological symptoms also have significant impacts on HRQOL in patients with HFS.
Correspondence: Dr Tan, Department of Neurology, Singapore General Hospital, Outram Road, Singapore 169608 (gnrtek@sgh.com.sg).
Financial Disclosure: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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