Blepharospasm (myokymia): surgical solutions

Eye twitches or flutters are fairly common and harmless for many of us. They are caused by a brief, occasional contraction of the orbicularis muscle, which usually settles back into place on its own. When they become repeated and potentially disruptive in daily life, this is known as blepharospasm. Let’s look at how this condition presents, how it differs from simple myokymia (the temporary twitching of the eyelid), and the solutions, both medical and surgical, that can act on the eyelids to relieve this discomfort.

What is blepharospasm?

Blepharospasm is a neuromuscular disorder characterised by involuntary, repeated contractions of the eyelid muscles. These contractions can occur in particular in the orbicularis muscle and the frontalis muscle. They may be confined to one side of the face (hemifacial spasm) or affect both sides. The condition may be limited to the eyelids or, more rarely, spread to other facial muscles.

This eye condition is most often benign (this is known as essential blepharospasm), although in rare cases it can progress to more severe forms (extreme difficulty opening the eye, brain lesions or, in the worst cases, Parkinson’s disease). It can nonetheless prove disabling in daily life, particularly when it comes to social interactions, and may require treatment (surgical or otherwise, depending on the extent and frequency of the contractions).

Blepharospasm should not be confused with orbicularis myokymia, a simple, harmless twitching of the eyelid that has similar symptoms (fasciculations, tensing of the orbicularis) but that are far milder, less frequent and temporary. Unlike blepharospasm, myokymia requires no surgery and usually resolves on its own: we cover it in the section below.

Myokymia: the harmless eyelid twitch (not to be confused with blepharospasm)

Myokymia (also called ocular myokymia or eyelid myokymia) refers to that small involuntary twitching of the eyelid that almost everyone has experienced: the lower eyelid, more often than the upper one, « jumps » or vibrates for a few seconds to a few minutes. It is a benign, transient contraction of the orbicularis muscle, harmless and with no consequences for vision, and has nothing to do with the chronic, severe nature of blepharospasm.

Why does the eyelid (or eye) twitch?

The causes of myokymia are almost always linked to lifestyle rather than to an illness. The most common triggers are:

• tiredness and lack of sleep;
• stress and anxiety;
• an excess of caffeine, tea or other stimulants;
• eye strain, particularly in front of screens, as well as dry eye;
• a possible magnesium deficiency or a mineral imbalance (potassium), often associated with tiredness;
• dehydration and excessive alcohol consumption.

How long does myokymia last and is it serious?

Myokymia is benign: it does not threaten vision and, in the vast majority of cases, is not a sign of any illness. Episodes come and go, last from a few seconds to a few hours and generally end up disappearing spontaneously within a few days, once the cause (tiredness, stress, too much coffee) has been addressed. There is therefore no reason to worry about an eye that twitches occasionally.

Myokymia, fasciculation or generalised myokymia?

Myokymia is often confused with fasciculation: a fasciculation is the isolated contraction of a small muscle unit, whereas myokymia corresponds to fine, continuous rippling of the muscle. When these twitches affect muscles other than the eyelid (calf, thigh, arm, etc.), this is referred to as generalised myokymia or « all over the body »; it usually remains benign and linked to tiredness, but a persistent or widespread form warrants medical advice to rule out a neurological cause.

How do you stop myokymia?

Myokymia is not really « treated » as such: it is usually enough to act on its triggers. A few simple measures are generally enough to stop the twitching:

• getting enough sleep and reducing tiredness;
• cutting down on caffeine and stimulants;
• managing stress (relaxation, breaks, physical activity);
• resting the eyes, taking breaks from screens and correcting any dry eye with artificial tears;
• ensuring good hydration and an adequate magnesium intake through your diet.

Myokymia: when should you see a doctor?

Medical advice is warranted when the twitching persists beyond two to three weeks, recurs very frequently, spreads to other facial muscles (around the mouth, hemifacial spasm) or is accompanied by forced closure of the eye, drooping of the eyelid, redness or other symptoms. These situations can in fact correspond to the onset of true blepharospasm or hemifacial spasm, which then call for specialist care.

Diagnosing blepharospasm

The condition is most often diagnosed by a neuro-ophthalmologist or an oculoplastic surgeon based on a clinical examination that reveals twitching or blinking of one eye (or even both eyes) as well as spasms in the eyelids (fasciculations). It also relies on what patients report, although they sometimes find it difficult to describe their discomfort precisely. A slit lamp or radiological examinations may also be used to characterise the abnormality but also to rule out any other potential neurological condition.

Blepharospasm: symptoms and forms of the condition

Blepharospasm can take different forms depending on the individual and present with variable symptoms (most often relatively benign), namely:

• a lowering of the eyebrow caused by contractions of the orbicularis muscle: this is known as facial dystonia;
• great difficulty opening the eyelids (focal dystonia of the pretarsal orbicularis);
• dry eye (dry eye syndrome) that may be accompanied by irritation;
• eye strain and heavy eyelids (particularly in front of screens) as well as hypersensitivity to light (photophobia);
• difficulty keeping the eyes open;
• eyelid contractions confined to one side of the face: this is known as hemifacial spasm;
• eyelid twitches that spread to other parts of the body (eyebrows, mouth, neck): this is Meige syndrome;
• secondary blepharospasm, where the eyelid twitching is only one symptom among other more significant ones, potentially linked to a neurological disease (brain lesions, Parkinson’s disease). This is then a generalised dystonia.

The causes of eyelid twitching

The causes of blepharospasm are still relatively poorly understood and uncertain. Unlike simple myokymia, it is not a vitamin or magnesium deficiency: essential blepharospasm is a dystonia of neurological origin. Eyelid twitching seems mainly linked to a conflict between an artery and a nerve, with a small branch of a cerebral artery (the cerebellar artery) compressing the facial nerve. These spasms and twitches can nonetheless be aggravated by external factors such as, in particular:

• stress;
• an excess of caffeine or stimulant products;
• irritation of the cornea linked in particular to dry eye;
• a genetic predisposition (heredity);
• age: blepharospasm more frequently affects people aged 50 and over.

The different treatment options for blepharospasm

Aesthetic medicine is the preferred treatment for managing essential blepharospasm, although surgical procedures on and around the eyelids may sometimes prove necessary. Treatment is generally performed by an ophthalmologist because of the risks involving eyelid positioning.

Botox injections in the eyelids by an ophthalmologist

Botulinum toxin injections in the eyelids are the gold-standard treatment for blepharospasm. While they do not treat the causes of the twitching, which remain difficult to identify, they paralyse the orbicularis muscle and significantly reduce the muscle spasms. They are carried out using fine needles in the eyelids in order to block the transmission of the nerve impulse to the muscles responsible for the contraction.

Botox injections are atraumatic and take only a few minutes, with no hospitalisation or anaesthesia required. They are effective for a large majority of patients with blepharospasm and have virtually no side effects, despite a few post-procedure guidelines to follow (avoiding lying down for a few hours after the injection, in particular).

The effect of these Botox injections is, however, temporary, and they need to be repeated every 3 to 6 months to prevent the eyelid contractions from returning.

Treatments that complement Botox injections

Alongside Botox injections, certain additional medications may also be given to patients as a complement, although their effectiveness is often limited. These include benzodiazepines (to relax the nervous system), muscle relaxants, antispasmodics (to limit nerve transmission) and anticholinergics (to regulate the neuromuscular junction).

Regularly applying eye drops to keep the eyes hydrated as well as relaxation and stress-management exercises can also help limit eyelid twitching in cases of essential blepharospasm.

Surgery for blepharospasm

When the contractions resist Botox injections, surgery for blepharospasm on the eyelids should be considered to put an end to this ocular discomfort.

Myectomy

A myectomy involves removing part of the muscles responsible for the eye twitching (muscle excision), either via the eyelid or via the eyebrow. Performed in a clinic under local anaesthesia (and possibly neuroleptanaesthesia), the procedure involves in particular excising the orbicularis muscles (orbiculectomy) and potentially the corrugator muscles (the horizontal muscles at the level of the frown lines) and procerus (the vertical muscles between the eyebrows).

The aim of the myectomy is then to reduce the muscle mass that can contract and therefore to minimise the impact of the spasms. The orbicularis muscles may even be removed entirely in the most disabling cases. It is carried out with the same rigour as other eyelid surgery procedures, preserving eyelid positioning as far as possible.

Eyelid suspension

Eyelid suspension involves placing strips of synthetic material (or, more rarely, the patient’s own tissue) under the skin in order to unify the frontalis muscle with the eyelid where the spasms occur. This unification allows the frontalis muscle (which is stronger) to hold up the drooping eyelid and thus prevent the spasm. This procedure is, however, rarely performed, particularly because of how demanding it is. It is used in particularly disabling cases, notably when the eyelid is excessively drooping (ptosis) or in the presence of eyelid paralysis.

Microvascular decompression

Microvascular decompression involves freeing the facial nerve when it is subjected to repeated compression by an artery or vein in the brainstem. This technique, which falls more within neurosurgery, applies only in cases of hemifacial spasm, that is, when the twitching is not limited to the eyelid but affects an entire side of the face. It is performed under general anaesthesia.

Blepharospasm treatment: what results can you expect?

The results of blepharospasm treatment are generally satisfactory for patients, allowing them to reduce eye blinking or even to make the eyelid twitching disappear completely.

In the case of Botox injections, the improvement is significant for 85 to 90% of patients, with 50% of them able to return to a perfectly normal life with no sign of twitching. The first results appear after 3 to 4 days and become particularly noticeable after around ten days, once the eyelid swelling has subsided. They last for 3 to 6 months depending on the individual and must then be repeated to maintain the paralysis of the muscles responsible for the spasms.

When botulinum toxin injections do not produce the desired effect, the myectomy treatment is preferred to treat essential blepharospasm. The surgical procedure then improves the situation for the great majority of patients (75%). Around 40% of them can even return to a perfectly normal social life with no discomfort in the eyelids.