Tics and Their Treatment

by Henry Meige; E. Feindel

The tonic variety of the same tic is constituted by a contraction of inordinate length, the outcome of which is the all but permanent maintenance of the eye in a half-closed position. The suspension of this tonic tic by volitional effort accentuates its distinction from contracture. In one of our patients a tic of this nature, which gave a singularly sleepy cast to the features, was easily relieved by suitable gymnastic treatment. The converse condition obtained in another case, where excessive gaping of the palpebral fissure contributed an unwonted fixity to the expression, which simultaneous contraction of the corrugator supercilii served to heighten into one of wild anger. These two tics corresponded to two diametrically opposed traits in their subject's character—viz. nonchalance and impatience respectively, and it is interesting to recall in this connection how the varying moods depend for their physiognomical delineation chiefly on the degree of curvature of the palpebral arc.

Valleix,[64] who employed the term "idiopathic facial convulsion" to designate tic, cites a case where even in moments of tranquillity the left eye seemed slightly smaller than its fellow, by reason of a feeble contraction of the orbicularis. Persistent grimaces of this kind resemble tics of attitude and stereotyped acts, and the possibility of their occurrence must not be overlooked, once the diagnosis of facial paralysis or spasm has been rigorously excluded.

The terms blepharospasm and blepharoclonus, sometimes applied to tonic and to clonic involuntary palpebral contractions respectively, ought to be strictly reserved for spasms and contractures properly so called. For example, von Graefe's case of blindness consequent on permanent closure of the eyelids in a child is undoubtedly one of blepharospasm. No tic could have been attended with such a result, whereas compression of branches of the trigeminal at their points of exit might determine reflex tonic contraction of the orbicularis, and so, for that matter, might a central lesion. Hence in these circumstances it is correct to use the word spasm.

Palpebral tics are among those that ordinarily begin by a spasmodic reaction to an extraneous source of irritation, such as that yielded by a foreign body, a speck of dust, an eyelash, or by any form of conjunctival inflammation.

Eyelid tics (says Parinaud[65]) are known to ophthalmologists as clonic blepharospasms. Their starting-point is always some peripheral stimulus, in particular an everyday variety of conjunctivitis characterised by the presence of granulations in the lower part of the sac. To discover these granulations it may be necessary to explore the internal aspect of the lid. In my opinion, they are a prolific cause of tic, especially in young children, and their removal effects a cure in the vast majority of cases.

It is only when the blinking abides in spite of the suppression of the exciting cause that it can be comprised in the category of tics, otherwise the fact of its being contingent on the continuance of the irritation shows it is a spasm.

A bright light sometimes suffices to initiate these conditions. During a course of sittings for her portrait, G., a little girl eleven years of age, acquired the habit of drooping one eyelid slightly to shield the eye from the somewhat glaring light of the studio, but the persistence of this movement in other surroundings was evidence of its degeneration into a tonic tic.

Noir quotes the case of one of his colleagues who was for a long time inconvenienced by a most disagreeable blinking, which he held to be a tic; but a simple explanation was forthcoming in the unusual length of some of the eyelashes on the outer part of the upper lid having caused their entanglement with others in the under one, and when they were cut off the spasm disappeared.

In the following instance, reported by Toby Cohn,[66] the diagnosis remains undetermined:

The protracted use of a magnifying glass in the left eye was the means, in a watchmaker, of inducing occasional localised twitches of the orbicularis, which were not slow, however, in spreading to the whole of the left half of the face. They may at first have been an involuntary motor response to nipping of palpebral twigs of the trigeminal, but at a later period their independence was constant and pronounced. With certain associated movements such as articulation or deglutition, or during the act of wiping the nose or shutting the eyes, the form they assumed was tonic. There were neither subjective nor objective sensory phenomena to note.