Blepharospasm

What is blepharospasm?

Blepharospasm is a type of eye twitching where the muscles in or around your eyes that open and close your eyes twitch or flex (spasm) rapidly and uncontrollably. In severe cases, the spasms can force your eyes shut, limiting your eyesight.

Research shows blepharospasm is mainly a neurological (nervous system-related) issue. Your eyes contribute to when and how the spasms happen.

What are the types of blepharospasm?

There are two main ways that blepharospasm happens:

• Primary. This is when blepharospasm happens on its own. Another name for this form is benign essential blepharospasm (BEB). This form is usually harmless, but it can still be disruptive.
• Secondary. This is when blepharospasm happens for a reason that experts can detect or diagnose. Secondary blepharospasm is more like a symptom of conditions that range from minor to severe (instead of a condition on its own). But it’s less common for the conditions that cause it to be severe or dangerous.

How common is blepharospasm?

Experts aren’t sure just how common blepharospasm is. Based on available data, experts estimate there are 2,000 new cases of BEB diagnosed each year in the U.S. Estimates on how many people have it range between 5,000 and 100,000 in the U.S. and between 128,000 and 2.4 million worldwide.

Those estimates are broad for multiple reasons. One reason is that benign essential blepharospasm is difficult to detect, so many cases go undiagnosed. Secondary cases also may be undercounted because providers list another condition as the cause. Lastly, blepharospasm can — and often does — go away spontaneously.

What are the symptoms of blepharospasm?

Eyelid twitching is the only symptom of blepharospasm. But what sets it apart from other similar conditions are certain features or details of the spasms, or the way you blink your eyes. They include:

• The degree and duration of the spasms. These refer to how much the spasms close your eyes (degree) and how long the spasms last (duration).
• You blink more than most people. Research shows people with blepharospasm blink more times per minute, even when they aren’t having noticeable spasms.
• It affects both eyes. One-sided eye twitching is rare with blepharospasm.
• You can’t control it. Experts classify blepharospasm as a type of dystonia, a movement disorder. The twitching from blepharospasm is involuntary, meaning you can’t consciously control or stop the movements as they happen.
• The spasms aren’t random. Blepharospasm twitching will have some sort of pattern to it instead of just flexing at random (a trained healthcare provider knows how to tell when spasms have patterns and aren’t random).
• Both eyelids spasm at the same time. Synchronized spasms aren’t common with other eye-twitching conditions.
• The spasms may improve briefly if you use “sensory tricks” or focus your attention. Sensory tricks can be things like humming, singing or touching your face. Experts aren’t sure why they help, but they’re a known feature experts watch for. Spasms may also lessen when doing things that take more concentration, like writing something down.

What causes blepharospasm?

Experts suspect that blepharospasm happens because of issues involving one of the following:

• The basal ganglia. This part of your brain helps with coordinating movements. Experts suspect that unusual activity in the basal ganglia can cause or contribute to blepharospasm.
• Cranial Nerve VII (CN VII). The seventh cranial nerve, or "facial nerve,” carries nerve signals from your brain to muscles in your eyelids. There’s evidence that blepharospasm can happen if cells in the facial nerve activate even though your brain isn’t sending signals through them.

Primary blepharospasm

BEB, the primary form of blepharospasm, is idiopathic, meaning it happens for reasons that experts don’t fully understand yet.

Secondary blepharospasm

Secondary blepharospasm can happen with several possible causes or contributing factors. They include:

• Other movement disorders. One movement disorder that can cause blepharospasm is Meige syndrome. Atypical forms of parkinsonism can also cause it (but this is rare).
• Inflammation-related conditions. When blepharospasm happens because of eye surface inflammation (keratoconjunctivitis) and eyelid inflammation (blepharitis), experts refer to it as “reflex blepharospasm.” This often causes dry eyes or burning eyes before blepharospasm starts.
• Light sensitivity (photophobia). Reflex blepharospasm can also happen with light sensitivity.
• Medications. Involuntary muscle movements can be a side effect of certain medications, especially drugs that treat Parkinson’s disease. Tardive dyskinesia from medications can also increase your risk of having blepharospasm.

What are the risk factors for blepharospasm?

Several factors have links to blepharospasm, including:

• Sex. People assigned female at birth (AFAB) are two to four times more likely to develop blepharospasm than people assigned male at birth (AMAB). Their spasms can be more frequent and/or severe, too.
• Age. Blepharospasm is most likely to happen between ages 50 and 70.
• Family history and genetics. About 20% to 30% of people with blepharospasm also have a biological family member with it. Research also links several changes to your DNA (mutations) to blepharospasm, but more research is necessary for experts to understand that link.
• Stress. Feeling stressed can cause blepharospasm and make attacks more frequent to happen.
• Fatigue. Blepharospasm attacks can happen more easily when you’re very tired.
• Medical history. Past and current eye injuries, eye conditions and nervous system conditions can all make blepharospasm more likely to happen.
• Mental health conditions. Conditions like obsessive-compulsive disorder (OCD), depression and anxiety all have ties to blepharospasm (but it isn’t always clear if blepharospasm causes or happens because of them).

What are the complications of blepharospasm?

Blepharospasm isn’t dangerous on its own, but it can be very disruptive or make ordinary situations hazardous. The spasms can make it hard to see or even force your eyes shut completely. When severe, the spasms can make it difficult or even impossible to drive, work, read and more.

Having blepharospasm can also contribute to significant stress and other mental health concerns. People who have blepharospasm commonly feel anxious or scared about the possibility of having a blepharospasm attack in public or around others. To avoid potential embarrassment or difficult situations, many people try to avoid situations where others might notice their condition, leading to issues like depression, anxiety and social isolation either developing or getting worse.

How is blepharospasm diagnosed?

Blepharospasm is difficult to diagnose, and many people need to see multiple providers from different medical specialties, such as:

• Ophthalmology. Eye care specialists, especially ophthalmologists, are often the first to see someone with blepharospasm (either because of the muscle spasms or other related issues like eye dryness and irritation).
• Neurology. Because it’s mainly a nervous system issue, neurologists are often the ones to diagnose and/or help treat blepharospasm.

Diagnosing blepharospasm usually involves both a physical and neurological exam. One specific test that might help (but isn’t always necessary) is electromyography.

Other tests might be possible, depending on other conditions your provider suspects or your medical history. Your provider can tell you more about other tests they think might help.

How is blepharospasm treated?

Blepharospasm is often treatable, but there’s no way to cure it yet. The treatments can also range from simpler, noninvasive methods to surgery. When blepharospasm happens with a specific cause, treating that cause is often helpful. Cases may go away on their own, but that’s uncommon and experts aren’t certain why this happens (or if it really goes away for good).

The most common and effective treatments specifically for blepharospasm include:

• OnabotulinumtoxinA injections (BOTOX®).
• FL-41 tinted lenses.
• Surgery.
• Acupuncture.

OnabotulinumtoxinA injections

OnabotulinumtoxinA is usually the first line of treatment for blepharospasm. Healthcare providers use it to weaken some of the muscles just enough to limit spasm-causing signals but not so much that you can’t blink your eyes.

These treatments usually involve four to eight injections with a tiny needle into the muscles around your eyes. The injections usually start working within two or three days and are usually effective for three to four months. But the effect isn’t permanent, so follow-up injections are almost always necessary. And some people may need larger doses as their bodies become used to the medication over time.

FL-41 tinted lenses

Filtering or blocking certain light wavelengths can reduce light sensitivity, which then helps blepharospasm. FL-41 is a specific pinkish tint that’s most effective. Glasses with these lenses are often called “blue light glasses” because they filter out blue wavelengths of light.

Glasses with FL-41 are usually available at places that specifically make or sell eyeglasses. You can also buy them online easily. And if you have prescription lenses, you might be able to get FL-41 lenses made with your prescription. Your eye care specialist can tell you more about whether that’s possible for your specific prescription.

Surgery

Surgery is usually a last resort because it involves permanently thinning the muscle to weaken it. But for people with very severe blepharospasm that doesn’t respond to onabotulinumtoxinA injections, surgery may be the best option.

Acupuncture

While it isn’t as common for treating blepharospasm, there’s research that indicates acupuncture can be an effective treatment. Your healthcare provider may be able to recommend accredited acupuncturists (including some who are also practicing medical doctors) who can help.

Can blepharospasm be prevented?

Blepharospasm isn’t preventable, and there’s no known way to reduce your risk of developing it. But you may be able to reduce how often the symptoms happen or how severe they are.

Some things that might help include:

• Using tinted lenses, hats or other means to help with light sensitivity.
• Learning if there are sensory tricks that work for you and using them.
• Limiting things that can make blepharospasm worse. That includes managing your stress and getting enough sleep.

What can I expect if I have blepharospasm?

Blepharospasm isn’t life-threatening, but it can disrupt your usual routine and activities. The condition often starts with minor effects and gets worse over time. Eventually, the spasms are severe enough that they may prevent you from keeping your eyes open.

If you have questions about things that can help you adjust or compensate, your healthcare provider may be able to offer suggestions or guidance.

How long does blepharospasm last?

Primary blepharospasm is usually permanent. But some research studies show that it goes away spontaneously in about 11% of cases. More research is necessary to confirm that and explain how the condition can go away on its own.

How do I take care of myself if I have blepharospasm?

When blepharospasm is severe, you may need to make certain changes to your routine and activities. Some examples include:

• Asking for help with transportation or using public transit options if it isn’t safe for you to drive.
• Knowing when to ask for help, like when you’re crossing the street or need assistance taking care of yourself.
• Adjusting your home or work environment to make it easier to get to things you need and reduce the risk of falls or injuries related to trouble seeing.
• Adjusting work or other activities if you can’t see well enough to do them.
• Learning to use supportive devices and services that can help you adjust or compensate for trouble seeing.

Does blepharospasm ever go away?

There’s research that shows primary blepharospasm can go away spontaneously in some cases, but it’s not common. More research is necessary to confirm if it can go away and why it does. Secondary blepharospasm may go away with treatment of the underlying cause.

What vitamin deficiency causes blepharospasm?

One small research study on 50 people from 2020 found that people with BEB were more likely to have lower levels of calcium and vitamin D, but that study didn’t specifically conclude that those deficiencies were causing blepharospasm. For now, there’s little to no research that conclusively shows blepharospasm can happen because of vitamin or mineral deficiencies.

A note from Cleveland Clinic

Blepharospasm may be a rare condition that involves small, uncontrollable muscle movements, but it can have a big impact on your life. This condition can make it hard to do things you once had no problem doing, like driving a car, reading or watching TV. And if you can’t predict when spasms will happen or how they’ll affect you, it can make leaving your house a source of anxiety, worry or even fear.

If you think you have symptoms that could be blepharospasm, you should see an eye care specialist. They can either start the process of testing for this condition or guide you to a specialist who can. Treatment can make all the difference, keeping your eyes open and preventing this condition from shutting you out of all the things you’d rather be doing.