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Excessive, involuntary blinking – blepharospasm


Blepharospasm is excessive, involuntary blinking. Benign essential blepharospam, or BEB, refers to this spasm in both eyes. Benign means the condition isn't life-threatening and essential means that it is of unknown cause.


Until the mid-20th century, BEB was thought to be a psychiatric condition but today it is believed to be a dysfunction of the blinking reflex control centre. Some patients with blepharospasm may have associated twitching (dystonias) of the face and neck.


Many people are not greatly troubled by BEB but it can have a major impact on a sufferer's life. Patients may be unable to drive, read, watch television or work.


Who is affected


BEB is rarely hereditary but affects three times as many women as men. Other risk factors include head or facial trauma or eye disease, such as dry eyes. Blepharospasm can occur at any age but sufferers are usually over 50.

Blepharospasm orbiculectomy pre1
Eyelids before myectomy (orbiculectomy) surgery

Blepharospasm orbiculectomy post1a
Eyelids after myectomy (orbiculectomy) surgery



The earliest symptom of BEB is simply an increased blink rate, often exacerbated by bright light. Over time, there is a gradual increase in the strength of the muscle contractions.


Spasms can last anything from seconds to minutes and primarily involve the muscles around the eye but may also involve the eyebrows. Some patients also have problems opening their eyes in the absence of spasm — a condition known as apraxia of eyelid opening. Occasionally, patients develop spasms that spread to the cheeks (Meige's syndrome) or to the neck (Brueghel's syndrome).


Generally, the condition worsens over a few years and then stabilises — remission is rare. Spasms can last any time from seconds to minutes and primarily involve the muscles around the eye but may also involve the eyebrows. A number of patients may also have problems opening their eyes in the absence of spasm (apraxia of eyelid opening).


Some people find that they are able to ameliorate their symptoms by manoeuvres such as singing, coughing, yawning or applying pressure at the temples. Others find that some activities or environments exacerbate the problem.


Many patients with BEB have dry eye symptoms, discomfort in bright light and crusting or inflammation of the eyelids (blepharitis). If these conditions are treated, the symptoms of BEB may improve.


Sources of information and support include the Dystonia Society and the Benign Essential Blepharospasm Research Foundation (USA).




You can download Mr Malhotra's quality of life questionnaire — he will ask you to fill it in before each consultation so that he can evaluate the extent and type of your disability, create an individually tailored treatment plan and review your progress.


Simple measures are the first step in treating BEB, although medical therapy can also play a part in relieving symptoms.

  • Sunglasses, particularly rose-tinted ones, provide protection from ultraviolet light and reduce discomfort caused by light (photophobia). The FL41 lens (FL-41/FL 41) has been shown to be the most effective rose-tint lenses to date. It can be obtained through your local optometrist or try www.norville.co.uk, e-mail: sales@norville.co.uk.
  • Some patients find their symptoms improve when one eye is covered. In a trial at the Corneoplastic Unit of the Queen Victoria Hospital, lead by Mr Malhotra, a group of these people were treated successfully by attaching a thin, translucent plastic filter (a Bangerter occlusion foil) to one spectacle lens.
  • Pinhole glasses are also worth considering, as they both reduce the discomfort produced by bright light and improve vision. These are available from web sites such as JD Harris.
  • If blepharospasm is relieved by pressure on the temples, then a spring-loaded device can be attached to the arm of your spectacles to provide lasting pressure on this area.
  • Dry eyes and blepharitis can be treated with lubricants and advice on hygiene.
  • Oral medication may be helpful but is usually only partially effective, short-lived and often has side effects.

Botulinum toxin


Medical therapy usually consists of local botulinum toxin (BTX) injections — 90 per cent of patients who receive BTX treatment are clinically improved, according to an American Academy of Ophthalmology survey of 4,340 patients.


Treatment typically results in a 70 per cent reduction in symptoms. Side-effects do not usually last long and include temporary drooping of the eyelid (10-15 per cent of cases), dry eyes (up to five per cent) and short-term double vision (up to two per cent).


What to expect

  • Side effects are uncommon — you may feel a mild burning sensation with the injection or experience some tingling for up to two or three days after treatment.
  • Minimal bruising may occur.
  • There may be some mild redness of the skin — this usually lasts only one or two hours.
  • Rarely, there may be weakness of nearby muscles if Botox spreads unexpectedly.
  • If treatment is being given to the deep areas of the eyelid, there may be temporary double-vision if the Botox spreads unexpectedly.

Eyelid surgery


In rare cases, patients who do not gain much relief from BTX may be offered eyelid surgery. The most widely-used procedure involves removing the dominant eyelid muscle responsible for the spasms in an operation known as a myectomy (orbiculectomy) or orbiculectomy.


Many surgeons, including Mr Malhotra, prefer to perform surgery to the upper eyelids first and only rarely consider lower eyelid surgery at a later date. This staged approach is believed to minimise risks of surgery. Myectomy (orbiculectomy) has been shown to benefit more than 80 per cent of patients and to deliver a level of improvement comparable to the results of BTX treatment.


Surgery, either performed separately or at the time of myectomy (orbiculectomy), can also correct many of the secondary eyelid and eyebrow changes that can occur as a result of longstanding BEB. These include constant droopy eyelids (ptosis) and significant descent of the eyebrows (eyebrow ptosis). An eyelid lift (blepharoplasty) can remove excess upper eyelid skin (dermatochalasis).


What to expect

  • Symptoms of blepharospasm are usually better within a few days of surgery.
  • Your vision may be blurred for a month, which may prevent you from driving — check that you can read a number plate at 20 metres, which is a legal requirement.
  • There will be bruising and swelling around the cheeks and eyelids — swelling usually reduces after a week, while bruising may persist for a month.
  • If you deal with the public, it's wise to take 14 days off work until bruising and swelling have reduced considerably.
  • Incision lines often bleed a little in the first week.
  • You will need to use artificial tears to lubricate dry eyes — you can normally stop after two months, although some people need them for longer.
  • Your eyelids may look unbalanced and you may have some difficulty closing them completely for the first few weeks — this normally settles down within two months.

All procedures begin with a consultation. For full information about what to do before and after surgery, see Patient information – care plan for eyelid or orbital surgery.


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