Abnormal involuntary eyelid closure and facial movements can often be debilitating. It occurs without the person control, with little warning. It can affect a person’s ability to see and have a considerable effect on their self- confidence, self-esteem and ability to socialise.
Over the last 25 years, Mr Uddin has treated many patients experiencing eyelid and facial spasms. He directed the Blepharospasm and Toxin Service at Moorfields Eye Hospital for 15 years, establishing the nurse-led toxin treatment. This service originally established by Professor Richard Collin is the largest of its kind in the country.
“Involuntary eyelid and facial movements can be a sign of blepharospasm, hemifacial spasm, myokymia and synkinesis, as well as side-effects of certain drugs. It’s important to accurately identify the condition and the underlying cause. There are many effective treatment options available to improve the symptoms”.
What is blepharospasm?
Blepharospasm is an excessive contraction of the eyelid muscles, which cause the eyelids to close. It may start in one eye to begin with, but frequently people have it in both. Those with a blepharospasm may experience rapid, frequent blinking or twitching, or difficulty opening their eyelids (eyelid apraxia). Sometimes it can worsen when a person is stressed or tired, or when exposed to bright light. In rare cases, the blepharospasm may also be associated with involuntary facial movements including the lower face, mouth and neck.
Blepharospasm is thought to be caused by a dysfunction within the basal ganglia (part of the brain responsible for controlling movement). The spasm may be triggered by psychological reasons such as stress, bereavement or grief, as well as physical factors such as dry and irritable eyes. There may be a hereditary role, as many individuals with this condition report a family history of a blepharospasm.
The uncontrolled or involuntary closure of eyelids or twitching is symptomatic in a number of other conditions. These include:
- Hemifacial spasm
- Meige syndrome
- Apraxia of eyelid opening
- Facial nerve palsy
- Synkinesis or aberrant regeneration
- Parkinson’s disease
- Trigeminal neuralgia
- Tourette syndrome
Frequently, the cause of the blepharospasm can be established through a thorough clinical examination and medical history. Muscle function tests such as an electromyography (EMG) are sometimes carried out. In rare cases a neurological exam may be needed; this could include special sequence magnetic resonance imaging (MRI) or computed tomography (CT) scans.
Eye drops or systemic medications may sometimes be prescribed. These can be combined with massage treatment for certain pressure points around the eyes, which has been shown to help in some patients. For those experiencing light sensitivity (photophobia) eye drops and sunglasses may be recommended.
For those individuals experiencing blepharospasm triggered by a psychological reason such as stress or bereavement, understanding the diagnosis and possible causes is helpful. Mr Uddin works alongside established psychologists specialising in these areas.
An effective treatment for people with a moderate to severe blepharospasm is Botox therapy. Botulinum toxin (Botox) is injected to the muscles around the eyes, blocking signals from the nerves and effectively weakening the muscles, reducing and breaking the cycle of the spasm. It also reduces the discomfort and abnormal sensation associated with blepharospasm.
The procedure only takes a few minutes and involves injecting small quantities of botulinum toxin into various muscles around the eyes and face. Most patients experience a little discomfort, but the injections are usually not painful. The effects of the injection start to work within a few days.
Most patients may then need a repeat injection every 4-9 months to maintain the effect, with some needing it more frequently. A significant number of patients have only ever needed one injection.
Possible side effects to the Botox treatment include bruising and swelling, and rarely poor eye closure, a droopy upper eyelid and double vision. These are often temporary and wear off after one or two weeks. Although very unlikely, the Botox treatment can sometimes cause an allergic reaction.
Is surgery used to treat blepharospasm?
Botox can be combined with a surgical procedure called an extended blepharoplasty (orbicularis stripping). This involves removing some of the orbicularis oculi muscle and a small amount of skin from the eyelid. This procedure is similar to a cosmetic upper eyelid blepharoplasty and can enhance the aesthetic of a person’s face and is completed under local anaesthetic.
In combination with ptosis surgery (strengthening of eyelid opening), it can be very effective.
Hemifacial spasm usually occurs on one side of the face with twitching movements around the eyelid and lower face. This will need investigating, usually with an MRI scan, in order to check for any disruption of the facial nerve (nerve that controls facial movements).
Apraxia of the eyelids is a particular type of blepharospasm, where a person finds it difficult to open their eyelids, often raising their eyebrows to help. It is commonly associated with Parkinson’s disease and is treated with a Botox injection or surgery.
Facial synkinesis refers to the development of linked and involuntary eyelid and facial movements, for example when a person opens their mouth it causes their eyelid to twitch. These are usually caused by abnormal connections in the facial nerves after they have been damaged and have regenerated. It is seen in conditions such as Bell’s palsy.
Myokymia refers to a twitching of only the eyelid. It is very common and can affect the upper or lower eyelids. Causes include anxiety, stress, fatigue, alcohol and caffeine.
Trigeminal neuralgia is a chronic pain condition, in which a person experiences facial pain, varying in intensity. It may be caused by compression or damage to the trigeminal nerve, which provides sensation to the face.
Meige syndrome or Brughel syndrome is a rare neurological movement disorder characterised by involuntary contractions of the muscles of the jaw, tongue and spasms of the muscles around the eyes. The cause of the condition is unknown and symptoms tend to develop in middle-aged people (between 40-70 years).