The most effective treatment consists of the injection of botulinum toxin into several sites in the orbicularis oculi and adjacent facial muscles. The benefit lasts for 3 to 6 months and repeated cycles of treatment are usually required. There appear to be few adverse systemic effects because of the low doses used. In the treatment of blepharospasm, a variety of antiparkinsonian, anticholinergic, and tranquilizing medications may be tried, but one should not be optimistic about the chances of success. A few of our patients in the past had temporary and partial relief from L-dopa. Sometimes the blepharospasm disappears spontaneously (in 13 percent of the cases in the series of Jankovic and Orman). Thermolytic destruction of part of the fibers in the branches of the facial nerves that innervate the orbicularis oculi muscles is reserved for the most resistant and disabling cases.
Other Causes of Blepharospasm
There are several clinical settings other than the one described above in which blepharospasm or a condition that simulates it may be observed. In the days following cerebral infarction or hemorrhage, the stimulus of lifting the patient’s eyelids may lead to strong involuntary closure of the lids. Reflex blepharospasm, as Fisher has called this phenomenon, takes liberty with the term as it more in the character of an apraxia of opening of the lids. It is more commonly associated with a left than a right hemiplegia. A homolateral blepharospasm has also been observed with a small thalamomesencephalic infarct. In patients with Parkinson disease, progressive supranuclear palsy, or Wilson disease and with other lesions in the rostral brainstem, light closure of the eyelids may induce blepharospasm and an inability to open the eyelids voluntarily.
We have seen an instance of blepharospasm as part of paraneoplastic midbrain encephalitis, and there have been several reports of it with autoimmune disease such as systemic lupus but the mechanism in these cases is as obscure as for the idiopathic variety. Also among our patients have been two with myasthenia gravis and blepharospasm of the type described by Roberts and colleagues, but we have been unable to ascertain if this represented a second disturbance or simply an exaggerated response to keeping the lids open. Finally, eye closure with fluttering of the lids in patients with a high degree of suggestibility is usually indicative of a psychological disorder. Blepharospasm induced by pain from ocular conditions such as iritis and rosacea of the eyelids has already been mentioned.
Lingual, Facial, and Oromandibular Spasms (Meige Syndrome)