Blepharospasm: A Clinical Overview

A concise guide to eyelid dystonia—how to distinguish benign eyelid myokymia from chronic blepharospasm, when to test, and what helps.

Topic: Movement Disorders Level: Intro / Intermediate Tags: blepharospasm, dystonia, myokymia, botulinum-toxin

Overview

Blepharospasm is an involuntary contraction of eyelid muscles—most often the orbicularis oculi—leading to excessive blinking or forceful closure that can impair reading, driving, or screen use. It is a focal dystonia. Spasms may start unilaterally but frequently become bilateral. Short-lived eyelid twitching (eyelid myokymia) is common and benign; chronic benign essential blepharospasm is a persistent dystonia that can be disabling.

Clinician tip: Ask patients to keep a brief symptom diary—patterns around caffeine, sleep loss, or stress often emerge.

Features & triggers

  • Eyelid myokymia (transient): days-long unilateral twitching; linked to fatigue, poor sleep, excessive screens, stress, and caffeine; medication effects possible.
  • Blepharospasm (chronic): blinking → sustained closure; may cause “functional blindness” despite normal acuity.
  • Pathophysiology: abnormal excitability in basal ganglia–brainstem circuits; genetic and environmental contributors under study.
  • Association with systemic disease: rare coexistence with neurologic disorders reported, but blepharospasm itself is not a marker of MS, ALS, or other degenerative disease.

Diagnosis

  • Clinical diagnosis from history and examination.
  • Imaging not routinely required; consider if atypical (e.g., hemifacial spasm suggesting vascular compression, other cranial neuropathies).
  • EMG rarely necessary outside research or complex cases.
Red flag: Persistent unilateral clonic facial contractions with synkinesis suggest hemifacial spasm—evaluate for neurovascular conflict.

Treatment snapshot

  • Lifestyle & reassurance: sleep hygiene, stress reduction, and limiting caffeine for transient myokymia.
  • First line for chronic blepharospasm: botulinum toxin injections to orbicularis oculi; benefit typically lasts 3–4 months; repeat as needed.
  • Adjuncts (variable benefit): clonazepam, trihexyphenidyl, baclofen—use selectively given side effects.
  • Refractory cases: surgical myectomy considered by experienced centers.
Pearl: Map prior injection sites and responses—small adjustments in dose and placement often resolve “waning effect.”

References

  1. Practical reviews on blepharospasm and focal dystonias; consensus statements on botulinum toxin use in movement disorders.

Educational discussion. Not a substitute for clinical judgment. Consider local protocols and individual factors.