Blepharospasm - symptoms, causes and treatment

Key Information

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TIME OF PROCEDURE

30 mins

DOWNTIME

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DISCOMFORT LEVEL

1 out of 5

AVERAGE SESSION REQUIRED

Every 3 months

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What is blepharospasm?

Blepharospasm is a rare neurological condition characterised by involuntary muscle contractions around the eyes, causing frequent blinking, forced eye closure, and in some cases, difficulty opening the eyes (known as apraxia of eyelid opening). This condition, also called benign essential blepharospasm, can extend beyond the eyelids, sometimes affecting other facial muscles and causing involuntary movements of the tongue, mouth, and neck; around 30% of patients experience these additional symptoms. In severe cases, it may even impact the larynx, leading to a hoarse or whispering voice.

Triggers such as bright light, stress, and fatigue can worsen the spasms throughout the day, often significantly affecting vision and daily functioning. While there is no cure for blepharospasm, a combination of medical and surgical treatments can help most patients regain normal control over their eye and facial muscles, greatly enhancing their quality of life.

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What are the types of blepharospasm?

Blepharospasm is classified into two main types: primary essential and secondary. Each type has distinct causes and progression patterns, impacting diagnosis and treatment approaches.

Primary essential blepharospasm

Often referred to simply as benign essential blepharospasm (BEB), this form occurs independently of any other diagnosed condition. While generally harmless, BEB can significantly disrupt daily activities due to the involuntary and frequent blinking or eye closure it causes. The exact causes of primary blepharospasm remain largely unknown, making it a challenging condition to predict and manage.

Secondary Blepharospasm

Secondary blepharospasm, on the other hand, is directly linked to other identifiable conditions. It acts more as a symptom rather than a standalone diagnosis and can be associated with a range of underlying issues, from minor irritations to more serious neurological disorders. Despite the potential severity of its causes, the conditions leading to secondary blepharospasm are often not life-threatening but require targeted treatment to manage the blepharospasm they provoke.

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What are the symptoms of blepharospasm?

Blepharospasm symptoms primarily include frequent, uncontrollable blinking and involuntary eyelid closure, often affecting both eyes simultaneously. Patients may experience excessive blinking, eye irritation, and a sensation of tension or heaviness around the eyes, which can worsen with bright light or environmental triggers such as wind or pollution.

As blepharospasm progresses, spasms can spread to other facial muscles, leading to additional symptoms like jaw clenching, grimacing, or tongue movements. In severe cases, patients may struggle to keep their eyes open for extended periods, affecting vision and causing functional blindness during spasms. Activities requiring visual focus, like reading or driving, can exacerbate symptoms, while others, such as laughing or singing, may provide brief relief.

How is blepharospasm diagnosed?

Diagnosing blepharospasm begins with a comprehensive clinical eye examination conducted by an ophthalmologist or neurologist. During this examination, the specialist will discuss symptoms and patient history to identify patterns associated with blepharospasm. Given its neurological nature, patients may also undergo a neurological exam to assess underlying nervous system factors.

Blepharospasm can sometimes be challenging to diagnose, requiring patients to consult multiple specialists. In complex cases, electrodiagnostic tests, such as electromyography (EMG), may be used to confirm the diagnosis by measuring muscle activity.

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What are the causes of blepharospasm?

The causes of blepharospasm are multifaceted and can be broadly classified into primary and secondary categories. In primary, or idiopathic, blepharospasm, the exact cause remains unknown, although it’s believed to involve irregular activity in the basal ganglia—a part of the brain responsible for coordinating movement. Genetic predisposition may also play a role, as patients with a family history of neurological movement disorders, including blepharospasm, are more likely to develop the condition.

Secondary causes of blepharospasm are linked to identifiable factors such as chronic eye irritation, including dry eyes or blepharitis, and neurological disorders. Chronic irritation can trigger a reflex response, disrupting the normal blink reflex and leading to involuntary spasms.

Our recent research at Moorfields Eye Hospital in London has also shown that blepharospasm patients have an underlying abnormality in the nerve layer of the corneal epithelium (the outer layer of the cornea of the eye) and associated decreased sensitivity of the ocular surface. Similar sensory abnormalities have been identified in other dystonias and neurological movement disorders, in which sustained or repetitive muscle contractions result in twisting or abnormal fixed postures. This suggests that decreased sensory stimulation to the brain can cause an input/output mismatch, which can cause blepharospasm

What are the risk factors for blepharospasm?

Several factors increase the risk of developing blepharospasm, including certain demographic and health-related elements. People aged 50 to 70 are at a higher risk, and those assigned female at birth are two to four times more likely to experience blepharospasm than those assigned male. Additionally, a genetic predisposition may exist, as 20% to 30% of individuals with blepharospasm report a family history of the condition, suggesting a potential hereditary link.

Certain lifestyle and health conditions can also elevate the likelihood of blepharospasm. High levels of stress and fatigue are known to trigger or worsen spasms, while a history of eye injuries or other neurological disorders may contribute to its development. Mental health conditions, including obsessive-compulsive disorder (OCD), depression, and anxiety, are also associated with a higher incidence of blepharospasm, although the exact relationship remains under study.

What are the complications of blepharospasm?

While blepharospasm is not life-threatening, it can significantly impact a patient’s daily life and overall well-being. Severe spasms may force the eyes to close involuntarily, resulting in temporary vision impairment that can hinder activities such as driving, reading, and working. This impairment can make certain tasks unsafe or unmanageable, limiting independence and daily functioning.

Blepharospasm treatment options

How is blepharospasm treated?

Though there is no cure for blepharospasm, a range of treatments can effectively reduce symptoms and improve quality of life. The primary approach involves botulinum toxin (BoNT) injections, which are widely recognised as the most effective and commonly used treatment. In some cases, oral medications or lifestyle adjustments are also recommended. Surgical options are generally reserved for patients with severe cases that don’t respond to other treatments.

BoNT injections

Botulinum toxin type A injections, often known as Botox, are the preferred treatment for blepharospasm. Administered through a series of tiny injections around the eyes, Botox works by blocking nerve signals to the muscles, preventing spasms. Most patients experience significant relief within 3 to 5 days, with the full effect observed by two weeks. The results generally last for three to four months, making ongoing treatment necessary to maintain symptom control. For many, this long-term solution brings substantial improvement to daily life.

Other uses of BoNT injections around the eye

In addition to treating eyelid spasms, BoNT injections can be used to target surrounding facial muscles that may also be affected, such as those in the brow or upper face. This comprehensive approach provides further symptom relief and can improve the patient’s overall comfort and appearance.

Alternative treatments

For those who may not respond fully to BoNT, alternative treatments are available. Oral medications can help manage muscle activity, though these are generally less effective and may come with side effects. Other options include physical therapy, FL-41 tinted lenses for light sensitivity, and lifestyle adjustments such as managing stress and fatigue, which can exacerbate symptoms.

Can I undergo surgery for blepharospasm?

Surgery is often a possibility for cases that do not respond to other treatments. A variety of different surgical options are available including:

While effective, surgery carries more risks and is recommended only when other treatments have proven unsuccessful. The exact plan for surgery and likely outcomes will be depend on the nature of the blepharospasm.

Whist surgery can be helpful, it will not obviate the need for regular botox injections.

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Hemifacial Spasm

What causes hemifacial spasm?

Hemifacial spasm (HFS) is a rare neurological condition involving involuntary contractions of the facial muscles on one side of the face. Unlike blepharospasm, which affects both eyes, hemifacial spasm usually begins around the eye and gradually progresses down the face. The primary cause of HFS is irritation or compression of the facial nerve, often due to a nearby blood vessel pressing against it, which results in misfiring nerve signals that trigger muscle contractions. Other causes include injury to the facial nerve, and in rare cases, the presence of a tumour. Although HFS is not painful, it can interfere with normal facial expressions and create feelings of embarrassment and self-consciousness.

How is a diagnosis made?

Diagnosing hemifacial spasm involves a thorough neurological examination to confirm symptoms and assess nerve function. To rule out other possible conditions, such as brain tumours or aneurysms, imaging tests like MRI scans are performed. Electromyography (EMG) and nerve conduction velocity (NCV) studies may also be conducted to measure muscle activity and the speed of nerve signals. These tests help determine the exact cause of the spasm, guiding the most suitable treatment approach.

What treatments are available?

Several effective treatments are available for hemifacial spasm, each tailored to the severity and progression of symptoms.

Medication

Muscle relaxants may be prescribed to ease spasms in mild cases. However, these medications can have side effects such as drowsiness, nausea, or skin rashes, and patients are monitored closely to avoid dependency and ensure safe levels in the bloodstream.

BoNT Injections

Botulinum toxin type A injections (BoNT) are one of the most common and effective treatments for hemifacial spasm. Small doses of BoNT are injected into the affected muscles to reduce contractions, providing relief within about three days. Results last up to three months, with repeated injections required for sustained effect. Some patients may experience side effects like temporary facial weakness or drooping, but most find the benefits far outweigh these minor drawbacks.

Surgery

For severe, persistent cases, surgery may be recommended. A procedure called microvascular decompression can be performed to relieve pressure on the facial nerve. During this surgery, a tiny sponge is placed between the nerve and the compressing blood vessel, which prevents further nerve irritation. Although surgery carries risks, the majority of patients report significant improvement and a return to normal activities within two months post-procedure.

Each of these treatments offers a pathway toward managing HFS, with tailored care depending on the individual’s needs and condition severity.

FAQ

How to prevent blepharospasm?

While there is no guaranteed way to prevent blepharospasm, managing lifestyle factors can help reduce the likelihood or frequency of symptoms. Reducing stress, ensuring adequate sleep, and avoiding environmental irritants such as bright lights or wind can alleviate potential triggers. Using protective eyewear and practising regular eye hygiene, particularly for those with dry eyes or blepharitis, can also contribute to symptom management.

How much does blepharospasm treatment cost?

Information on the cost of blepharospasm treatment will vary based on the specific therapies recommended. For more details on pricing, please contact The Ezra Clinic directly.

Is BoNT treatment safe?

Botulinum toxin (BoNT) treatment is considered a safe and effective option for managing blepharospasm. When administered by experienced specialists, BoNT injections target specific muscles to reduce spasms without affecting other facial functions. Side effects may include temporary eyelid drooping or mild facial weakness, but these are generally minimal and resolve on their own. The Ezra Clinic’s team uses refined techniques to minimise risks and maximise patient comfort and results.

Is blepharospasm painful?

Blepharospasm itself is not painful, though it can be uncomfortable or disruptive. Patients may experience sensations of eye strain, tension, or heaviness around the eyes due to the frequent contractions. In severe cases, these symptoms can lead to temporary vision impairment, but they do not usually cause physical pain.

Will I need repeat blepharospasm treatment?

Repeat treatments are usually necessary for ongoing relief from blepharospasm. BoNT injections, for example, generally last between three and four months, after which symptoms may gradually return, requiring follow-up injections. Many patients find that regular treatment significantly improves their quality of life.

Is blepharospasm the same as hemifacial spasm?

Blepharospasm and hemifacial spasm are distinct conditions. Blepharospasm involves involuntary blinking or eye closure affecting both eyes and is often due to issues with the blink reflex. Hemifacial spasm, by contrast, affects only one side of the face and is caused by compression or irritation of the facial nerve, resulting in muscle spasms from the eye down to the mouth.

If my eyelids twitch, do I have blepharospasm?

Not necessarily. Occasional eyelid twitching, known as myokymia, is common and often temporary, usually caused by factors like stress, caffeine, or lack of sleep. Blepharospasm is a more persistent, involuntary condition that usually affects both eyes and may require medical treatment. If eyelid twitching becomes severe or persistent, it’s advisable to consult a specialist.

How long does blepharospasm last?

Blepharospasm is generally a chronic condition, though symptoms may vary in intensity. Episodes can last from a few seconds to several minutes, and while treatments can manage the symptoms effectively, the condition itself often persists over time.

Does blepharospasm ever go away?

In some rare cases, blepharospasm may improve or resolve on its own, but this is uncommon. Most patients experience ongoing symptoms that require management through regular treatment. Long-term relief can often be achieved with therapies such as BoNT injections, although permanent resolution is rare.

How common is blepharospasm?

Blepharospasm is a relatively rare condition, affecting around 5 in 100,000 people. It is more prevalent among individuals aged 50 and above and is slightly more common in those assigned female at birth. Despite its rarity, specialised clinics like The Ezra Clinic offer dedicated expertise to support those living with blepharospasm.