Painful Eyelid Spasms

    • CE credits 2 hours
    • COPE code 55831-AS / 114818
    • Available until Dec 20, 2020
    • Free



  • To review the pathophysiology and secondary causes of blepharospasm
  • To review the mechanism of action and administration of botox for patients with blepharospasm
  • To review other medical, surgical, and supportive treatments for blepharospasm


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).

Quick Question

What is the most likely etiology of this patient’s condition?

  • Idiopathic
  • Compression of the facial nerve

    Compression of the facial nerve along its course is the typical cause of hemifacial spasm, a related condition. However the clinical picture here is not consistent with hemifacial spasm, which is usually unilateral and associated with facial muscle weakness.

  • Medication-induced

    Blepharospasm may be associated with several medications including antihistamines, dopaminergic drugs, and sympathomimetics. However, both Zoloft and hydrocholorothiazide are unlikely to cause blepharospasm.

  • Functional/hysterical blepharospasm

    Functional/hysterical blepharospasm is a diagnosis of exclusion that is characterized by blepharospasm in response to an emotionally traumatic event. The patient's 5 year history makes this less likely, and such a diagnosis should not be considered unless there is no alternative explanation.


Blepharospasm is a form of dystonia characterized by spontaneous, spasmodic, bilateral, intermittent or persistent, involuntary contractions of the orbicularis muscle.1 It is one of the more common types of dystonias, occurring at a prevalence of 12-133 per million. 2 Approximately 1 in every 10,000 people will develop the condition at some point in their lives,3 and it affects more than 20,000 people in the United States.4

Blepharospasm is more common in females with a male : female ratio of 1:2 to 1:3. It typically affects patients in the 5th–7th decade of life,5 with a mean age of onset of 56, and 2/3 of patients being age 60 or older. 6 Only rarely does it affect individuals below the age of 50. 3 It may occur in isolation or as part of a spectrum of dystonic movements of other facial or cervical muscles. 7

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