Overview

This information is about the different types of treatment for blepharospasm and hemifacial spasm.  

Blepharospasm

Blepharospasm causes the muscles around your eyes to spasm involuntarily. It is thought to happen because of loss of control of the normal blink reflex. Frequent blinking and uncontrollable eye closure are common characteristics of blepharospasm. In the most severe cases, a person might be unable to open their eyes for several minutes.

Some people find that their blepharospasm is made worse by things such as bright light, stress, and social interactions. The pattern of the spasm might change throughout the day. For example, you might have few or no symptoms when you wake up in the morning, but they could start to appear or get worse when you are tired or stressed. 

Hemifacial spasm

Hemifacial spasm causes similar spasms around the eye, but only affects 1 side and usually involves other muscles (such as cheek or mouth) on the same side of the face. Some patients with hemifacial spasm have a blood vessel in the brain that is too close to the facial nerve. When the blood vessel touches the nerve it can cause the spasms. Another cause is abnormal rewiring of the facial nerve after a facial nerve paralysis, as it heals again over time. This is called aberrant facial nerve regeneration.

Treatment of blepharospasm and hemifacial spasm

Management of these conditions includes simple measures such as:

• keeping your eyes comfortable with moisturising drops 
• using sunglasses (especially FL41 filters) 
• occasionally covering (occluding) 1 eye (which can stop the spasms temporarily)

The most effective first treatment for these conditions is injections of botulinum toxin type A.

Other treatment options

Some neurologists (doctor who specialises in the brain and nervous system) also use tablets to control spasms, although these can have side effects. They are usually recommended when there is only a partial response, or if there is an adverse reaction to botulinum toxin. 

Botulinum toxin type A injections

Injections, such as botulinum toxin and Dysport^®, are medical treatments that are used by doctors for the treatment of many muscle problems. The injections help to relax muscles, so can be used to relax the muscles around the eyes. This reduces the involuntary closure of the eyes and helps patients to keep their eyes open when they want. They are generally not used for spasms in the lower face. 

Small amounts of botulinum toxin are injected into the muscles around the eye to be treated. Usually 3 to 6 injections are given at different sites, taking 1 or 2 minutes. The injections might be a little painful, but most people tolerate the discomfort easily. If patients find the injections particularly difficult, anaesthetic cream (EMLA) can be applied to the skin before they are given.

When the botulinum toxin starts to work

It takes about 3 to 5 days before the injections take effect, and up to 2 weeks for the full effect to be seen. You should then notice a reduction in the amount of spasm you have around the treated eyes. The effects of the botulinum toxin generally last for about 3 months but then start to wear off. If you want to maintain the effect, you'll need regular follow-up injections. Most patients repeat their injections about every 3 months.

Side effects

The side effects of botulinum toxin treatment around the eyes relate to it working too well, or accidentally leaking into other muscles round the eye.

All the side effects are temporary and will wear off as the botulinum toxin wears off.

Any side effects should resolve within 3 months.

Side effects include:

• poor closure of the eye (if the botulinum toxin works too well). This can result in dry eye, discomfort, or blurry vision
• a droopy upper lid (if the muscle holding up the eyelid is involved)
• double vision (if the muscles moving the eye are involved)

You might also get some bruising at the injection sites.

Very rarely, patients can develop resistance to the treatment, making it less effective.

Botulinum toxin very rarely causes side effects in other areas of the body. However, you might get flu-like symptoms of feeling tired with a headache. Side effects usually disappear within a few days or weeks. 

If you are concerned about any side effects, please call the ophthalmic day case unit, phone: 020 7188 9545.

Long-term treatment

Most patients with blepharospasm or hemifacial spasm find that botulinum toxin injections are very helpful in managing their condition. The injections do not cure the condition but can help to control it. Most patients choose to remain on long-term botulinum toxin injections every 3 to 4 months, but the injections can be stopped at any stage if needed. Some patients find that they can extend the time between their injections over time.  

Other uses of botulinum toxin injections around the eye

• abnormal nerves connecting to their tear glands (causing excessive amounts of watering from the eye, especially when eating)
• correcting rare imbalances in the muscles around the eyes
• to deliberately induce a droopy lid
• correcting squints