The man who blinked too much

aka Ophthalmology Befuddler 004

The nurse half chuckles and shakes her head as she hands you the next chart. It seems your next patient’s main problem is that he can’t stop blinking!


Q1. What is blepharospasm?

Uncontrollable blinking as a result of repeated involuntary orbicularis oculi contraction.

It is always bilateral, but may briefly be unilateral at onset. It subsides when asleep.

Q2. What causes blepharospasm?

It is either idiopathic or due to an irritative lesion of the lid or eye (e.g. blepharitis, dry eyes, corneal foreign body).

Q3. What is the differential diagnosis of blepharospasm?

The differentials include a few weird and (not-so-)wonderful conditions:

  • hemifascial spasms
    idiopathic or a brainstem lesion; may need an MRI
  • eyelid myokymia —
    that funny lower eyelid twitch you get when you’re stressed and tired!
  • Tourette syndrome —
    tics and coprolalia
  • Tic doloroux —
    CN5 distribution pain associated with wincing
  • tardive dyskinesia —
    dyskinesia is not limited to the eyelids
  • apraxia of eyelid opening —
    e.g. Parkinsons; there is no muscle spasm, instead there is failure to voluntarily open the eyes

Q. How is blepahrospasm treated?

Treatment of the underlying cause is the mainstay, but severe cases may need botox injections or surgery. If there is no obviously correctable cause, it may be time to call one of your friendly ophthalmology colleagues (again)…


  • Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
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