Blepharospasm (Eyelid Spasm)

What is Eyelid Spasm?

The orbicularis oculi muscle, which closes our eyelids, is formed by numerous muscle fibers arranged circularly on top of one another, as thin as a hair. This muscle bundle contracts to enable the blinking movement and closes our eyelids.

A similar muscle structure is found around our lips, and the flawless arrangement of this muscle structure allows our eyes to remain closed while we sleep unconsciously. It also allows us to reflexively close our eyelids in milliseconds if a foreign object approaches our eye. Additionally, if we wish, we can keep our eyelids closed with a force that even the strongest fingers cannot open.

Furthermore, unlike all other muscles, this muscle structure involuntarily contracts 12-15 times per minute, performing the blinking movement, which is highly beneficial for our eyes, without our conscious control. It also enables us to consciously blink using the same muscle.

This unique arrangement that allows the orbicularis muscle fibers to function both voluntarily and involuntarily can sometimes become disrupted, leading to temporary or permanent spasms in part or all of the eyelid.

What Causes Eyelid Spasms?

There are different types of eyelid spasms, and each of these conditions has different underlying causes.

Eyelid spasms can arise from a foreign object that has entered the eye or from an eye disease that causes sensitivity to light, as well as from excessive fatigue of the fine muscle fibers.

Persistent and severe spasms may be related to excessive stimulation of brain waves, but they can also rarely be caused by certain diseases within the brain, vascular anomalies, or masses.

What is Eyelid Twitching?

Sometimes, a very annoying muscle spasm or twitching movement occurs in our eyelid. These spasms, medically known as myokymia, cause twitching in our eyelids. Many patients describe this condition as "my eye is twitching." This sudden, often intermittent, and self-resolving condition is quite uncomfortable.

What Causes Eyelid Twitching?

Eyelid twitching is the result of a temporary cramp in a part of the circular orbicularis muscle fibers in the upper or lower eyelid. The severity of the twitching depends on the amount of muscle fibers involved.

The most common cause of these intermittent spasms is muscle fatigue, which is often due to factors like tiredness, lack of sleep, and stress. The orbicularis muscle fibers, which are the thinnest and most frequently moving muscle fibers in our body, can quickly be affected when they do not receive the necessary fluids and electrolytes (salts),leading to temporary spasms.

Some underlying eye conditions such as allergies, infections, dryness, or disturbances in the eye surface-lid contact can also cause eyelid twitching.

Although rare, if the eyelid twitching persists uninterrupted for more than a week, it may be necessary to investigate an underlying neurological condition.

How is Eyelid Twitching Treated?

A history and eye examination are very important in the treatment of eyelid twitching. The onset, progression, whether it occurs intermittently or continuously, how long it has been present, and whether there are any eye-related complaints are questions that will determine the treatment approach. If there are underlying eye diseases, treating them will speed up the healing process.

Eyelid twitching is usually a benign condition that resolves on its own. Increasing fluid intake, consuming mineral water and fruit to balance electrolyte loss, reducing caffeine, maintaining good and regular sleep, and reducing stress will usually cause the twitching to resolve quickly. For people with light sensitivity, wearing sunglasses and taking regular breaks for those who use computers intensively will also help with the healing process.

What is Blepharospasm?

The term ‘blepharospasm’ is derived from the combination of ‘blepharo’ (eyelid) and ‘spasm’ (contraction),and essentially serves as an umbrella term for all eyelid spasms.

What is Essential Blepharospasm?

The term ‘essential’ is used in many different ways in science, but when used with blepharospasm, it refers to a condition with an unknown cause, not related to any underlying known disease. Essentially, the full term is ‘Benign Essential Blepharospasm’; the word ‘benign’ means ‘non-cancerous’ or ‘harmless.’ In this condition, there is no malignant disease such as a tumor, cancer, or aneurysm behind the severe eyelid spasms. ‘Benign Essential Blepharospasm’ usually occurs after the age of 50 without an underlying disease and involves severe spasms in both eyelids. This disease occurs in approximately 5 out of 100,000 people, and women are twice as likely to experience it compared to men.

The condition may sometimes begin with mild increases in blinking and progress to spasms or may start directly with spasms and twitches. These spasms, which start around the eyes, may later spread to the cheeks, around the mouth, and rarely to the neck muscles. The spasms appear intermittently during the day, and disappear completely during sleep at night. The frequency and severity of the spasms may vary depending on the patient’s stress or anxiety levels.

The spasms in this condition are completely involuntary, and this is not a psychological disorder. As a physician who has worked with this condition for many years, I can say that patients with this disorder often share traits such as being anxious, meticulous, unable to ignore problems, having a sensitive nature, getting stuck in unsolvable situations, and being upset by many things. Additionally, they often have a caring family member or support person who looks after them selflessly.

There are many theories and scientific studies aimed at explaining the source of this disorder. Based on my personal observations and studies, the most plausible theory, in my opinion, is that the imbalance in the central control system of the brain, which processes visual signals and controls involuntary blinking and eyelid closing, becomes disrupted over years of excessive load due to the patient’s genetic and character traits.

‘Essential Blepharospasm’ is a clinically diagnosed condition with a very typical spasm pattern, and an oculoplastic surgeon or neurologist familiar with this condition can quickly make the diagnosis. While MRI imaging is not required for diagnosis, it would be helpful to rule out brain-related issues in order to name the condition ‘Benign Essential Blepharospasm.’

Essential Blepharospasm and Dry Eye Relationship

In the early stages of the disease, when the spasms are not very severe, the discomfort and increased blinking may be mistakenly diagnosed and treated as dry eye disease, leading to a delayed diagnosis. Although many patients may have mild or severe dry eye symptoms, this is not the cause of the condition. Treating dry eye will not correct the disease. However, it is crucial to perform a detailed eye examination in every blepharospasm patient and treat any underlying conditions such as dry eye or allergies that may cause photophobia or surface-related problems. These treatments are important supportive therapies for the disease's progression.

How is Benign Essential Blepharospasm Treated?

‘Benign Essential Blepharospasm’ is a chronic (persistent) and progressive (progressing) condition. It cannot be spontaneously cured or eliminated with a single treatment.

Botulinum toxin (Botox) treatment was developed in the 1960s by Ophthalmologist and Oculoplastic Surgeon Dr. Alan Scott, following a ten-year study, to treat these types of spasms.

If untreated, the condition can lead to ‘functional blindness,’ a situation where the patient is unable to open their eyes and cannot perform even basic daily tasks such as driving or walking. Botox, which has been safely used for more than 50 years, has revolutionized the treatment of this condition and can stop spasms for an average of 3 months, enabling patients to lead normal lives during that period.

An important method of treatment is myectomy surgery, in which part or all of the orbicularis oculi muscle, which closes the eyelid, is removed. This surgery, developed by Dr. Richard Anderson (the mentor of many oculoplastic surgeons, including Dr. Robert Kersten, who trained me),aims to remove the muscle responsible for spasms, helping patients maintain their daily lives without difficulty. After this surgery, occasional Botox applications may still be necessary.

Recently, a topic of research is the use of filtered lenses that block wavelengths to reduce the severity of spasms by regulating visual stimuli. While promising results have been obtained in some patients, no lens/filter has yet been found that effectively reduces the disease in all patients, and studies are ongoing in this area.

What is Hemifacial Spasm?

Hemifacial spasm refers to the contraction of one side of the face. This condition is caused by the facial nerve, which controls facial muscles, being affected on one side. Initially, the spasms are intermittent, but over time they can become persistent. Stress and fatigue increase the severity of the spasms. The spasms are painless and occur outside the patient’s control. This condition typically begins in the 40s and is more common in women.

The spasms usually start around the eyes, sometimes appearing as eye twitching in the early stages. Therefore, prolonged eye twitching that does not resolve should be monitored as a potential early sign of hemifacial spasm. The disease may start with strong blinking, and over time, other muscles in the lower part of the face (such as the nose and mouth) may also be affected. In some patients, spasms of both the eyes and face start simultaneously and intensify.

Unlike blepharospasm, the spasms in this condition continue during sleep. This disease has a very typical spasm pattern, and its diagnosis is made through clinical examination by an experienced physician.

In approximately 60% of hemifacial spasm cases, the underlying problem is that the facial nerve is in close proximity to a blood vessel or a vascular bulge as it passes through the brain. It can rarely be caused by nerve damage due to a brain tumor or trauma. Therefore, brain MRI imaging should always be requested in patients with hemifacial spasm, although it is common not to find any problems in the imaging.

Hemifacial Spasm Treatment

The treatment options for hemifacial spasm include botulinum toxin therapy and a surgical procedure, known as a decompression surgery, performed by neurosurgeons.

Neurological drugs such as carbamazepine, clonazepam, and baclofen, which slow down brain signals, may provide limited support for other treatments but are generally not preferred due to their side effects and limited contributions.

The neurosurgery procedure involves creating an opening in the skull to locate the blood vessel causing pressure on the facial nerve, and placing a metal plate between the two structures to relieve the pressure.

The preferred treatment for hemifacial spasm today is botulinum toxin therapy, which has been safely used for over 50 years to treat this condition. The effects of Botox in this disease last about 6 months, which is longer than its effectiveness in blepharospasm.

How to Relieve Eyelid Spasms?

As long as the eyelid spasms are not caused by neurological conditions, they will resolve on their own with adequate rest, balanced nutrition, and stress reduction.

In cases of persistent spasms caused by other diseases, the most common treatment used is botulinum toxin (Botox) therapy.

Eyelid Spasm Treatment

Eyelid spasm treatment depends on the underlying issue. First, any eye-related disorders that may cause the spasms should be thoroughly evaluated and treated.

In addition to reducing stress, maintaining regular sleep, adequate fluid intake, and a balanced diet, if the spasms are due to essential blepharospasm or hemifacial spasm, the most common and effective treatment method is botulinum toxin injections. In some cases, surgical treatment options are also available. Please discuss the advantages and disadvantages of these alternatives with your doctor.

Which Doctor Should I Visit for Eyelid Spasms?

Since eyelid spasms concern the eyes and sometimes arise from eye conditions, a thorough eye examination is essential. Ophthalmologists specialized in oculoplastic surgery or neuro-ophthalmology, or neurologists with neuro-ophthalmology training, are equipped with the knowledge to diagnose and plan treatment for these conditions through clinical examination. The Botox application techniques used for these conditions are quite different from cosmetic applications, so careful consideration should be given when choosing a doctor.