Benign Essential Blepharospasm

Benign essential blepharospasm (BEB) is a movement disorder characterized by involuntary, sustained contractions of the muscles around the eyes, causing forced eye closure. Despite having normal vision, people with BEB may be functionally blind during spasms because they cannot keep their eyes open.

Understanding Blepharospasm

BEB is a focal dystonia—a movement disorder affecting specific muscles. In BEB, the orbicularis oculi muscles (which close the eyelids) contract involuntarily and forcefully. The cause is dysfunction in brain circuits controlling movement, not a problem with the eyes themselves.

Symptoms

Eyelid Spasms

• Involuntary forced eye closure
• May start as increased blinking
• Progresses to sustained spasms
• Both eyes usually affected (bilateral)
• Cannot voluntarily keep eyes open during spasms
• May be intermittent initially, becoming more frequent

Triggers and Aggravating Factors

• Bright lights (photophobia)
• Stress
• Fatigue
• Reading
• Driving
• Wind
• Dry eyes
• Watching TV or screens

Sensory Tricks (Geste Antagoniste)

Some patients find relief through:

• Touching the face
• Wearing glasses (even non-prescription)
• Talking or singing
• Chewing gum
• Pulling on eyelid skin

These tricks work temporarily in some but not all patients.

Associated Conditions

• Dry eye—very common, may precede or coexist
• Photophobia—light sensitivity
• Lower facial spasms—Meige syndrome
• Apraxia of eyelid opening—difficulty initiating eye opening

Progression

• Often begins with increased blinking
• May be attributed to dry eye or stress initially
• Gradually worsens over 1-2 years
• Usually stabilizes at plateau level
• Rarely remits spontaneously

Causes

The exact cause is unknown, but:

• Basal ganglia dysfunction—brain circuits controlling movement
• Not psychological—it's organic brain dysfunction
• Not caused by stress—though stress can worsen symptoms
• Genetic factors may play a role
• Secondary causes should be ruled out (medications, other neurological conditions)

Diagnosis

Clinical Diagnosis

Diagnosis is based on clinical features:

• Bilateral, symmetric eyelid spasms
• Involuntary forced eye closure
• No other explanation found

Rule Out Secondary Causes

• Review medications (some can cause dystonia)
• Exclude other neurological conditions
• Eye examination (rule out eye surface disease as sole cause)
• Neurological examination

Important Distinctions

Condition	Features
Blepharospasm	Forceful closure, both eyes, no twitching
Hemifacial spasm	One side only, twitching, includes other facial muscles
Eyelid myokymia	Brief twitching, usually one lid, benign
Dry eye	Blinking, irritation, responds to lubrication
Ptosis	Drooping (not spasm), can open eyes voluntarily

Treatment

Botulinum Toxin Injections

First-line treatment—highly effective

• Botox injections into orbicularis oculi muscles
• Weakens overactive muscles
• Effects last 3-4 months typically
• Repeat injections needed
• 90%+ of patients benefit

What to expect:

• Small needle injections around eyes
• Takes several days to work
• May need dose adjustment
• Side effects: temporary drooping, dry eye, bruising

Oral Medications

Limited effectiveness, but may be tried:

• Benzodiazepines (clonazepam)
• Anticholinergics
• Baclofen
• Often used as adjuncts

Other Treatments

FL-41 tinted glasses

• Rose/amber tint
• May reduce light-triggered spasms
• Worn indoors and out

Treatment of dry eye

• Often coexists
• May reduce triggers
• Artificial tears, prescription drops

Surgery (Rarely Needed)

Myectomy

• Surgical removal of eyelid muscle
• Reserved for treatment-resistant cases
• Good results in experienced hands
• May still need Botox afterward

Living with Blepharospasm

Practical Tips

• Keep eyes lubricated
• Wear wrap-around sunglasses
• Use FL-41 tinted lenses
• Manage stress and fatigue
• Take breaks during visual tasks
• Inform employer if needed

Driving

• May be unsafe during severe spasms
• Discuss with doctor
• May need to avoid driving in certain conditions
• Botox often restores driving ability

Support

• Benign Essential Blepharospasm Research Foundation (BEBRF)
• National Spasmodic Dystonia Association
• Support groups

Prognosis

• Most patients achieve good control with Botox
• Chronic condition requiring ongoing treatment
• Quality of life significantly improved with treatment
• Does not worsen vision (eyes are healthy)
• May spread to lower face in some (Meige syndrome)

Frequently Asked Questions

Is blepharospasm caused by stress?

No. Stress can worsen symptoms but doesn't cause BEB. It's a neurological movement disorder, not a psychological condition. This misconception unfortunately delays diagnosis for many patients.

Will I go blind?

No—your eyes are healthy. The problem is involuntary eyelid closure, not vision loss. However, untreated BEB can cause "functional blindness" because you can't keep your eyes open.

Do I have to get Botox injections forever?

BEB is typically a chronic condition, and most patients need ongoing Botox every 3-4 months. Some patients find they can extend intervals over time, but the condition rarely resolves completely.

Are there side effects from Botox?

Temporary drooping of the eyelid or brow can occur but usually resolves. Dry eye and bruising at injection sites are possible. Serious side effects are rare when performed by experienced practitioners.

Why does touching my face help temporarily?

This is called a sensory trick (geste antagoniste) and is common in focal dystonias. The sensory input seems to temporarily reset the brain circuits controlling the muscles. It doesn't work for everyone and usually becomes less effective over time.

References