Benign Essential Blepharospasm

    • Involuntary bilateral lid closure
    • May be a focal dystonia, a facial tic, or idiopathic
    • Core clinical features
      • Intermittent bilateral activation of the orbicularis oculi on both sides produces squeezing of the eyelids and eye closure
      • No pertinent neurologic or systemic illness
    • Possible accompanying clinical features
      • Initial symptom is photophobia
      • Episodes become more frequent and easier to provoke over time
      • Exacerbated by social interactions
      • Relieved by ritual maneuvers like humming, meditating, touching face
      • Tic-like mouthing movements (“Meige syndrome”)
    • Bilateral severe ptosis
      • Does not have orbicularis oculi contraction
    • dermatochalasis
      • Caused by obvious loose overhang of upper lid skin
      • Trap: many patients with blepharospasm are initially misdiagnosed as having ptosis or dermatochalasis, triggering inappropriate surgery for these conditions
    • Post-paretic facial contracture
      • Follows facial palsy, is almost always unilateral, and is never intermittent
    • Hemifacial spasm
      • Differs in being strictly unilateral
    • Dry eye syndrome, other surface keratopathies, uveitis, cone dystrophy, albinism, meningitis, migraine, anxiety
      • Orbicularis oculi contraction is less than in benign essential blepharospasm and differs in being triggered by bright light (“photophobia-induced squinting”)
    • Apraxia of lid opening
      • Is often accompanied by parkinsonian features
    • Rule out imitators by finding their corroborative signs
      • Corneal epithelial defects, rapid tear break-up time, as in ocular surface disease
      • Anterior uveitis
      • Narrowed retinal arterioles, as in cone dystrophy
      • Bradykinesia, rigidity, tremor, as in parkinsonism
      • Involuntary facial movements, as in tic disorder
    • Try anxiolytic medication or psychotherapy if you diagnose anxiety
    • If no underlying cause is found, prescribe periocular botulinum toxin injections
    • Botulinum toxin injections usually relieve symptoms for 3–4 months, can be repeated, and will usually provide long term relief
    • Side effects of botulinum toxin injections--ptosis, exposure keratopathy, diplopia—are temporary and tolerable
    • Patients who fail botulinum toxin treatment may sometimes get relief from anxiolytics or psychotherapy aimed at obsessive compulsive disorder
    • Orbicularis oculi myectomy is rarely necessary

    Lid Disorders

    Ptosis Lid Retraction Apraxia of Lid Opening Benign Essential Blepharospasm Hemifacial Spasm