An 85 year old female presents to your clinic with a 5 year history of painful “spasms” of her eyelids. Approximately 5 years ago, she started noticing intermittent “twitching” of her right eye. A few months later this was followed by intermittent spasms that caused the eye to close completely. Over time she developed similar symptoms in the left eye, and says the spasms have been increasing in both severity and frequency. The symptoms are worse in the right than the left eye. At worst they occur several times a day and impair vision. In between episodes she complains of grittiness of the eyes. She recalls no involvement of other facial muscles.
The patient's past medical history is significant for hypertension and depression for which he is on hydrochlorothiazide and Zoloft, respectively. There is no history of eye diseases or surgeries.
On exam visual acuity is 6/9 bilaterally. There is excess skin in the eyelids as well as mild excoriations presumably from the patient trying to manually open the lids during spasm. There is no weakness of facial muscles noted. No spasms are noted during the patient’s visit. A photograph of the patient’s face is shown below (not during a spasm).