Bilateral Blink Research Articles

Design recommendations for voluntary blink interactions based on pressure sensors

Voluntary blink control is vital in eye-controlled human–computer interaction (ECHCI). Pressure sensors, known for their low power consumption and strong resistance to interference, are suitable for blink detection. Existing research has predominantly focused on sensor materials and signal processing, and studies on the characteristics and optimized design of voluntary blink actions in ECHCI remain relatively limited. Therefore, this study presents a blink detection system based on pressure sensors and investigates the efficiency of voluntary blink actions. We examined the effects of two independent variables, blink count (single, double, and triple) and blink side (bilateral and unilateral), on recognition accuracy and three time-related variables. Subsequently, the subjective workload and evaluation experiments were conducted for each blink action. The results indicate that the blink count has a more pronounced impact on interaction efficiency and comfort, with continuous blink actions exceeding three blinks not being recommended. Bilateral blinks were perceived as more natural and comfortable than unilateral blinks. Moreover, we discovered that the participants exhibited greater attentiveness and focus when performing double bilateral blink actions, making it suitable for important commands. Based on the experimental results, the top three recommended voluntary blink actions are single bilateral blink (SB), double bilateral blink (DB), and single unilateral blink (SU). Finally, a test involving controlling the movement of a toy car using the recommended blink actions validates the usability of the actions and detection system. These findings provide valuable guidance for the design and optimization of voluntary-blink interaction systems, further enhancing this interaction method’s feasibility.

Lesion Localization and Prognosis Using Electrodiagnostic Studies in Facial Diplegia: A Rare Variant of Guillain-Barre Syndrome.

BackgroundThe etiology of facial nerve palsy is diverse and includes herpes zoster virus, Guillain-Barre syndrome (GBS), otitis media, Lyme disease, sarcoidosis, human immunodeficiency virus, etc. The lower motor neuron type facial nerve palsy is usually caused by an ipsilateral facial nerve lesion; however, it may be caused by a central lesion of the facial nerve nucleus and tract in the pons. Facial diplegia is an extremely rare condition that occurs in approximately 0.3% to 2.0% of all facial palsies. Electrodiagnostic studies including direct facial nerve conduction, facial electromyography (EMG), and blink reflex studies are useful for the prognosis and lesion localization in facial nerve palsy.MethodologyThis retrospective, observational study was conducted at the Neurophysiology Unit, Hamad General Hospital, Doha, Qatar. This study included 11 patients with bilateral facial weakness who visited for electrodiagnostic studies in the neurophysiology laboratory.ResultsIn total, eight (72.7%) patients had facial diplegia, eight (72.7%) had hypo/areflexia, seven (63.6%) had facial numbness, and five (45.5%) had cerebrospinal fluid albuminocytological dissociation. The most frequent cause of facial diplegia in this study was GBS (81.9%). Direct facial nerve conduction stimulation showed that nine (81.8%) patients had bilateral facial nerve low compound muscle action potential amplitudes. The bilateral blink reflex study showed that eight (88.8%) patients had absent bilateral evoked responses. Finally, the EMG study showed that five (55.5%) patients had active denervation in bilateral sample facial muscles.ConclusionsBilateral facial nerve palsy is an extremely rare condition with a varied etiology. Electrodiagnostic studies are useful in detecting the underlying pathophysiologic processes, prognosis, and central or peripheral lesion localization in patients with facial diplegia.

Results of balance tests and gait parameters are not dependent on each other in patients with balance problems

Prepulse inhibition (PPI) is a neurophysiological phenomenon whereby a weak stimulus modulates the reflex response to a subsequent strong stimulus. Its physiological purpose is to avoid interruption of sensory processing by subsequent disturbing stimuli at the subcortical level, thereby preventing undesired motor reactions. An important hub in the PPI circuit is the pedunculopontine nucleus, which is also involved in the control of posture and sleep/wakefulness.To study the effect of posture (supine versus standing) on PPI, induced by somatosensory prepulses to either upper or lower limb. PPI was measured as the percentage inhibition of the blink reflex response to electrical supraorbital nerve (SON) stimulation.Sixteen healthy volunteers underwent bilateral blink reflex recordings following SON stimulation either alone (baseline) or preceded by an electrical prepulse to the median nerve (MN) or sural nerve (SN), both in supine and standing. Stimulus intensity was 8 times sensory threshold for SON, and 2 times sensory threshold for MN and SN, respectively. Eight stimuli were applied in each condition.Baseline blink reflex parameters did not differ significantly between the two postures. Prepulse stimulation to MN and SN caused significant inhibition of R2. In supine but not in standing, R2 was significantly more inhibited by MN than by SN prepulses. In standing, SN stimulation caused significantly more inhibition of R2 than in supine, while the inhibition caused by MN prepulses did not differ significantly between postures.PPI induced by lower limb afferent input may contribute to postural control while standing.

The importance of a comprehensive assessment when tuning ankle-foot orthoses in cerebral palsy: a case report

Prepulse inhibition (PPI) is a neurophysiological phenomenon whereby a weak stimulus modulates the reflex response to a subsequent strong stimulus. Its physiological purpose is to avoid interruption of sensory processing by subsequent disturbing stimuli at the subcortical level, thereby preventing undesired motor reactions. An important hub in the PPI circuit is the pedunculopontine nucleus, which is also involved in the control of posture and sleep/wakefulness.To study the effect of posture (supine versus standing) on PPI, induced by somatosensory prepulses to either upper or lower limb. PPI was measured as the percentage inhibition of the blink reflex response to electrical supraorbital nerve (SON) stimulation.Sixteen healthy volunteers underwent bilateral blink reflex recordings following SON stimulation either alone (baseline) or preceded by an electrical prepulse to the median nerve (MN) or sural nerve (SN), both in supine and standing. Stimulus intensity was 8 times sensory threshold for SON, and 2 times sensory threshold for MN and SN, respectively. Eight stimuli were applied in each condition.Baseline blink reflex parameters did not differ significantly between the two postures. Prepulse stimulation to MN and SN caused significant inhibition of R2. In supine but not in standing, R2 was significantly more inhibited by MN than by SN prepulses. In standing, SN stimulation caused significantly more inhibition of R2 than in supine, while the inhibition caused by MN prepulses did not differ significantly between postures.PPI induced by lower limb afferent input may contribute to postural control while standing.

Influence of posture on blink reflex prepulse inhibition induced by somatosensory inputs from upper and lower limbs

BackgroundPrepulse inhibition (PPI) is a neurophysiological phenomenon whereby a weak stimulus modulates the reflex response to a subsequent strong stimulus. Its physiological purpose is to avoid interruption of sensory processing by subsequent disturbing stimuli at the subcortical level, thereby preventing undesired motor reactions. An important hub in the PPI circuit is the pedunculopontine nucleus, which is also involved in the control of posture and sleep/wakefulness. ObjectiveTo study the effect of posture (supine versus standing) on PPI, induced by somatosensory prepulses to either upper or lower limb. PPI was measured as the percentage inhibition of the blink reflex response to electrical supraorbital nerve (SON) stimulation. MethodsSixteen healthy volunteers underwent bilateral blink reflex recordings following SON stimulation either alone (baseline) or preceded by an electrical prepulse to the median nerve (MN) or sural nerve (SN), both in supine and standing. Stimulus intensity was 8 times sensory threshold for SON, and 2 times sensory threshold for MN and SN, respectively. Eight stimuli were applied in each condition. ResultsBaseline blink reflex parameters did not differ significantly between the two postures. Prepulse stimulation to MN and SN caused significant inhibition of R2. In supine but not in standing, R2 was significantly more inhibited by MN than by SN prepulses. In standing, SN stimulation caused significantly more inhibition of R2 than in supine, while the inhibition caused by MN prepulses did not differ significantly between postures. SignificancePPI induced by lower limb afferent input may contribute to postural control while standing.

Trigeminal laser-evoked potentials: a neurophysiological tool to detect post-surgical outcome in trigeminovascular contact neuralgia.

The aim of this study was to explore the nociceptive system of patients affected by trigeminal neuralgia (TN) secondary to documented vascular contact who underwent microvascular decompression. For that purpose, we used the classical trigeminal reflexes and the trigeminal laser-evoked potentials (tLEPs) before and after surgery, in order to verify any possible change after decompression and determine if there was any correlation between the neurophysiological parameters and the clinical outcome. Eleven patients affected by TN caused by trigeminovascular contact and 10 age-matched controls underwent conventional trigeminal reflexes (bilateral Blink Reflex/BR and Masseter Inhibitory Reflex stimulating infraorbital and mental nerves/MIR V2 and V3) and tLEPs. Patients repeated neurophysiological tests one week after surgery. Short-latency BR and MIR were normal in all patients before surgery and there was no statistical difference before and after surgery. Conversely, in patients before surgery, tLEPs' amplitudes were significantly lower in the affected than in the healthy side (p = 0.017 for V2 and 0.037 for V3 branches). After surgery, on the affected side, tLEP amplitude increased and the pre/post-operative difference was significant (p = 0.017 for V2 and 0.028 for V3 divisions). Nine patients referred satisfactory pain relief and the favourable clinical outcome correlated with the neurophysiological recovery. This study demonstrates that TN caused by trigeminovascular compression may be related to Aδ fibres impairment, and tLEPs are more sensitive than conventional trigeminal reflexes to reveal small fibre dysfunction and to monitor the post-surgical outcome in these patients.

The use of bilateral blink reflexes in intraoperative monitoring of facial-trigeminal nerves in cerebello-pontine angle operations

Background and Objective: Intraoperative monitoring (IOM) of facial nerve is routinely recommended in CerebelloPontine Angle (CP Angle) operations. Middle cranial nerves: V, VII, VIII are mainly involved since these nerves are sometimes separated by the tumor mass causing an inadvertent section of the facial nerve. Blink reflex could be elicited by stimulation of supraorbital branch of Trigeminal nerve which elicits EMG responses in facial muscles. Threshold, amplitude, latencies, pre-post surgery are strong predictors of postoperative facial function. Methods: In 17 cases of CP angle tumors (24-43 mm, by MRI) approached suboccipitally, we performed bilateral blink reflexes pre/intra/post surgery. The setup consisted of a Nicolet Endeavor IOM system( VIASYS Healthcare, 2005, USA) with the ability to perform several voltage/current stimulations and recordingsup to 20 Evoked Potentials and Electromyography (EMG) simultaneously. Bilateral blink reflexes were evoked by stimulation of bilateral supraorbital nerves. Stimulating pulses of 0.1 ms duration and 5-20 mA intensity were applied percutaneously at the intervals of 10-20 s. The orbicularis oculi muscle responses were recorded using surface electrodes. Early EMG responses (R1) and later reflex activities (R2) were elicited ipsi/contra laterally (R1/2-i/c). Every five successive trials were superimposed and the lowest latencies were used for comparison. Blink reflexes of each subject considered pathologic if: 1- Loss of R1-i,c to the operation side, latencies are more than 15 ms or side differences are 3 ms or more; 2- Loss of R2-i, latencies are more than 50 ms or side differences are 10 ms or more. 3- Loss of R2-c, latencies are more than 55 ms or side differences are 10 ms or more. Recordings were performed 2-3 days before operaration, intraoperative and 21 days after operation. Results: Before surgery, in 15 subjects, the amplitudes of R1-i responses were significantly lower than the R1-c. However, in 2 cases with tumor size of 39 and 43 mm, the R1-i s were absent while R2-c of opposite side of the tumor were weakly present. Intraoperative recordings were continuously jugged according to patient previous results. Post operation records of all subjects showed improved amplitudes in R1-i, R1-c and R2-c with significant reduction of latencies. Propofol or Propofol/Ketamine mixture plus narcotic is suitable to record stable reproducible blink responses. Atracurium or other non-depolarizing muscle relaxant should be avoided prior to EMG recordings. Conclusion: Direct facial nerve stimulation by surgeon is often difficult in large tumors until substantial tumor mass debulked and without knowledge of the location of the nerve it sometimes, could be too late. Saving facial nerve in CP angle operations has been widely studied but optimum predictive variables have yet to be determined. The main limitation of the study method was our inability to record the reflex during electrocautery which creates large artifacts that obliterate EMG signals at the times when the risk of thermal injury caused by cautery is high. To acquire IOM modalities, close collaboration of the anesthesiologist is necessary.

Intraoperative early change of latencies in Facial nerve function during Microvascular Decompression studied in patients with Hemifacial Spasm

Background: Primary hemifacial spasm (HFS) is reported mainly as a result of cross compression of blood vessel and facial nerve at its root exit zone (REZ). Generation of HFS could be due to hyperexcitability of facial nerve since microvascular decompression (MVD) has been an effective treatment in clinical experince of authors. Multimodal Intraoperative monitoring (MIOM) has been frequently used for care and constant evaluation of facial nerve during MVD. In HFS patients F waves of the facial muscle which is known to be induced from backfiring of facial motor nucleus, Blink reflexes and Lateral spread (abnormal muscle responses) before, during and after MVD have been used to evaluate the excitability of the facial motor nucleus and the treatment outcome after MVD procedure. Methods: In 9 female HFS cases with abnormal lateral spread in their facial Electromyography (EMG), patients history, preoperative physical examination, electrodiagnosis and MIOM were perfored using a Moltimodal 40 channels electrophysiologic monitoring system (Nicolet Endeavor, VIASYS Healthcare, 2005, USA). Free run EMG, Stimulated EMG, bilateral blink reflexes and facial F waves were set for MIOM as indicators of MVD effectiveness. Bilateral Orbicularis Oris/Oculi muscles were used for surface EMG recordings. Antidromic stimulatin of facial nerve branches and direct bipolar stimulation of the nerve in REZ, before and after its vascular contact at the site of operation applied by surgen. In all subjects, recordings were scheduled a week before, intaoperatively and every 2 weeks up to 3 months after operation. Results: In affected side of the face before MVD, threshold of F wave was reduced and excitability of blink reflex EMG responses were enhanced compared to the normal side. These responses remaind the same intraoperatively. In post operation recordings F waves and Blink reflex responses were as before in 7 subjects up to fourth week after the surgery, although with lower amplitude of the responses. These responses and Lateral spread of EMGs disappeared completely after 6 weeks. In 2 other subject these abnormal findings reduced slowly and subsequently disappeared after 12 weeks. In all cases, introperative recordings of F wave latencies and the latencies of R1 and R2 responses of blink reflexes were reduced significantly even before 20 minutes of decompression (P Propofol or Propofol/Ketamine mixture plus narcotic is suitable to obtain stable reproducible F waves and EMGs. Atracurium or other nondepolarizing muscle relaxant should be avoided. Muscle relaxants, mean arterial pressure (MAP) below 70 mmHg may cause bilateral reduction or loss of reflex responces and EMGs. In all cases, there was no postoperative clinically detectable complication. Conclusions: MIOM could be useful technique in all patients undergoing any procedures around cranial nerves. Monitoring can practically reduce possibilities of neurologic deficit and reduce the potential risk of interventions around facial REZ. We conclude that in MVD for HFS, the use of stimulated EMGs for evaluating involved facial nerve is not sufficent because, practically, it could be limited to the efferent nerve fibers not the nucleuses.In these settings and similar procedures, if monitoring systems are avaiable, alternative multimodal methods with greater sensitivity and efficacy should be explored. MVD seems to be effective procedure for treatment of HFS and monitoring would help to optimise the MVD. The study also supports the hypothesis that the hyperexcitability of the facial motor nucleus may be the main cause of hemifacial spasm. To aquire and maintain MIOM modalities, close collaboration of the anesthesioloist is nessesary.

Performing Saccadic Eye Movements or Blinking Improves Postural Control

To determine the relationship between eye movement and postural control on an undisturbed upright stance maintenance protocol, 15 young, healthy individuals were tested in various conditions. These conditions included imposed blinking patterns and horizontal and vertical saccadic eye movements. The directions taken by the center of pressure (CP) were recorded via a force platform on which the participants remained in an upright position. The CP trajectories were used to estimate, via a low-pass filter, the vertically projected movements of the center of gravity (CGv) and consequently the difference CP-CGv. An analysis of the frequency shows that regular bilateral blinking does not produce a significant change in postural control. In contrast, performing saccadic eye movements induces some reduced amplitude for both basic CGv and CP-CGv movements principally along the antero-posterior axis. The present result supports the theory that some ocular movements may modify postural control in the maintenance of the upright standing position in human participants.

Heterosynaptic long-term depression of craniofacial nociception: divergent effects on pain perception and blink reflex in man

Noxious low-frequency stimulation (LFS) of presynaptic nerve fibers induces long-term depression (LTD) of synaptic transmission. In vitro studies suggest a sole homosynaptic effect. Consequently, the present study addressed the hypothesis that LTD of craniofacial nociception in man is mediated by a homosynaptic mechanism. Nociceptive supraorbital afferents were excited by electric pulses via a concentric electrode in ten healthy volunteers. The electrically evoked bilateral blink reflex (BR) was recorded from both orbicularis oculi muscles by surface electrodes. The BR was evoked in blocks of ten electric stimuli each (0.1 Hz) with an interblock interval of 8 min. Conditioning noxious LFS (1 Hz, 20 min) was applied via concentric electrode either to the same site as BR test stimuli (ipsilateral) or to the corresponding contralateral forehead area (contralateral). LFS and test stimulus intensities corresponded to about threefold the pain threshold. After three baseline stimulus blocks, either conditioning ipsilateral or contralateral LFS were applied or stimulation was interrupted for 20 min as a control task. Afterwards, test stimulation blocks were continued for 40 min. Each volunteer participated in all three sessions on different days. Noxious LFS induced LTD of the BR independently from the side of conditioning stimulation. Pain perception decreased after ipsilateral LFS but not after contralateral LFS. The bilateral effect of noxious LFS on the BR provides evidence for heterosynaptic LTD based on bilateral projections of supraorbital nerve afferents onto spinal trigeminal nuclei. The divergent effect on pain perception may be due to a preferential contralateral projection of nociceptive afferents onto reflex interneurons but not onto trigeminothalamic projection neurons.

Nerve Stimulation for Regional Anesthesia of the Face: Use of the Blink Reflex to Confirm the Localization of the Trigeminal Nerve

A blink reflex is a bilateral eyelid closure in response to nociceptive stimuli. We hypothesized that elicitation of a blink by a stimulating needle may enhance performing regional anesthesia of the face. Thirty outpatients undergoing cutaneous surgery of the face were studied. A 2.5-cm insulated beveled stimulating needle was inserted at the emergence of the infraorbital nerve. On elicitation of a bilateral blink with 0.5 mA of stimulating current, bupivacaine 0.5% 3-7 mL was injected. Operative conditions were excellent. Blink response can be used to localize superficial branches of the trigeminal nerve. Elicitation of a blink response during nerve stimulation results in successful trigeminal block. Elicitation of a blink response during nerve stimulation results in successful trigeminal block.

Presentation of myasthenia gravis mimicking blepharospasm

About 90% of patients with MG develop ocular muscle weakness causing ptosis and diplopia. By contrast, the ocular features of blepharospasm and Meige syndrome (blepharospasm plus oromandibular dystonia) are caused by involuntary, forcible contraction of the orbicularis oculi, causing spasmodic blinking.1,2⇓ We report two patients with MG whose presentation with chronic blinking mimicking blepharospasm led to inappropriate treatment. ### Patient 1. A 73-year-old man presented to an ophthalmologist with a 2-year history of continuous involuntary blinking without symptoms or signs of ptosis or diplopia. Blepharospasm was diagnosed. Periocular injections of botulinum toxin (Botox, Allergan Ltd., Wycombe, UK) caused a complete bilateral ptosis lasting 4 weeks. Blinking returned as the ptosis improved. One year later, we noted frequent blinking and residual, nonfatigable ptosis. There was no frontalis overactivity, abnormality of eye movements, or weakness of eye closure. The rest of the neurologic examination was normal. Bilateral blinking tics were diagnosed, …

Bilateral centrotemporal spikes triggered by blinking: an unusual form of sensory input with related cortical EEG activity

Objective: To investigate the morphology, scalp topography and temporal relationship with orbicularis oculi muscle contraction of bilateral blink related spikes (BRS) in a 7-year-old boy with chromosomopathy, mild mental retardation and left spontaneous centrotemporal spikes (SS).Methods: The patient underwent video-polygraphic recordings with off-line analysis of SS and BRS by means of spike-averaging and orbicularis oculi contraction-locked averaging techniques respectively. EEG activity related to reflex blinking (evoked by glabellar tapping) was also studied.Results: SS and BRS presented the same morphology, characterised by four peaks (P1, N1, P2, N2). SS were located over the left centroparietal regions, while BRS were placed over both left and right centrotemporoparietal regions and constantly followed the contraction of orbicularis oculi with overlapping peak latencies over C3 and C4 electrodes (P1 72 ms; N1 115 ms; P2 164 ms; N2 236 ms). Reflex blinking evoked a small waveform with the same features as BRS.Conclusions: Our findings suggest that both involuntary and reflex blinking can act as a form of sensory stimulation probably engaging similar nervous pathways and cortical sources in generating EEG abnormalities: the trigeminal system.

Evidence for a facilitatory role of callosal afferents to the cat motor cortex in the initiation of conditioned bilateral movements.

The effects of selective transection of the rostralmost portion of the corpus callosum, which contains fibres interconnecting the motor cortices of the two hemispheres, on frequency of occurrence and latency of conditioned responses (CRs) in both eyes were examined in seven cats trained to blink in response to a 500-ms tone. A 100-ms air-puff delivered to one eye only (ipsilateral eye) 400 ms after tone onset was used as an unconditioned stimulus. Both before and after callosal lesion, bilateral CRs were the most frequent response pattern. Following callosal lesion, a statistically significant reduction in the percentage of CRs in at least one eye was observed in only two cats. In all seven animals, both before and after callosal lesion, the mean CR latencies of the ipsilateral eye were significantly shorter than those of the contralateral eye. Callosal lesion caused a significant increase in the mean CR latencies of both eyes in all subjects. These results provide evidence that the two hemispheres influence each other in controlling conditioned bilateral blinking by reciprocally exchanging facilitatory signals contributing to initiation of CRs in both eyes.

Startle and Emotion: Lateral Acoustic Probes and the Bilateral Blink

The affect-startle effect describes the modulation of the reflexive eyeblink response to a probe startle stimulus as a function of foreground emotional valence. Larger blinks occur during viewing of unpleasant slide foregrounds, relative to positive foregrounds. This effect has been obtained repeatedly using binaural acoustic startle probes. The current study examines this phenomenon for monaural probes administered to the left and right ears in separate blocks. Startle probes were presented during and between exposures to pleasant, neutral, and unpleasant slides, with the ear of presentation counterbalanced across subjects. Left monaural probes produced blink magnitudes that increased linearly from pleasant to unpleasant slide foregrounds, and appeared to be independent of attention or interest. Right monaural probes did not vary with foreground valence. These findings suggest that the startle probe indexes emotional processing that is lateralized in the central nervous system.

Blink reflex in man in response to stretching of extraocular muscles?

An unilateral oculo-palpebral reflex evoked by weakly tapping the eyeball is described. It has a latency of 8–9 msec and a well-synchronized aspect. It is often followed by a silent period lasting 20–80 msec and is accompanied by a reciprocal inhibitory pause in the homolateral frontal muscle. It is unaffected by local anesthesia of the homolateral supra and infraorbital nerves, but is abolished by a homolateral retrogasserian neurotomy. Our results suggest that this short-latency blink reflex is produced by the stretching of extraocular muscles. It seems, therefore, likely that it originates in extraocular muscle spindles whose primary afferents are known to run with the ophthalmic branch of the trigeminal nerve. This reflex response can be facilitated by voluntary activation of the opposite orbicularis oculi muscle and in spastic hemiplegic patients it is potentiated on the affected side. Stronger tapping of the eyeball evokes a bilateral blink reflex with characteristics of a nociceptive reflex. It is suggested that this reflex originates in pain receptors located in extraocular muscles.

Blinking and sleep.

AS normal blinking is involuntary, it might be expected that blinking would proceed at its normal or at a somewhat reduced rate during sleep, as with breathing and the heart-beat. This is not so, however, though little seems to have been published on the subject, especially on the quantitative side. Whereas many of the muscles are relaxed during sleep, “the muscular tone of the muscles which keep the eyes closed is undoubtedly increased”. Duke-Elder1 states that the occurrence of bilateral blinking movements “may be used as a test for the simulation of sleep”.