What are the causes of eye twitch (blepharospasm)?

Causes of Eye Twitch (Blepharospasm)

Eye twitching (blepharospasm) is primarily caused by stress, fatigue, caffeine consumption, and digital screen time, but can also result from more serious conditions such as blepharitis, myasthenia gravis, or medication side effects. 1, 2

Common Causes

Lifestyle and Environmental Factors

• Stress and fatigue - Most common trigger for temporary eye twitching
• Caffeine consumption - Excessive intake can stimulate muscle contractions
• Digital screen time - Extended use can lead to eye strain and twitching
• Dehydration - Inadequate fluid intake
• Alcohol consumption - Can trigger or worsen eye twitching
• Eye strain - From prolonged visual tasks or poor lighting
• Sleep deprivation - Disrupts normal muscle function

Medical Conditions

• Blepharitis - Inflammation of the eyelid margin causing irritation and twitching 1
• Dry eye syndrome - Insufficient lubrication leading to irritation
• Meibomian gland dysfunction (MGD) - Affects tear film stability 1
• Myasthenia gravis - Autoimmune disorder affecting neuromuscular junctions 2
  • Presents with variable strabismus and ptosis that worsen with fatigue
  • Incidence: 0.04 to 5/100,000 per year
  • Symptoms improve with rest and positive ice pack test
• Thyroid eye disease - Associated with thyroid disorders 2
• Benign essential blepharospasm - Focal dystonia with involuntary contractions 3, 4, 5
  • More common in women (female:male ratio of 2.8:1)
  • Mean age of onset: 55.8 years
  • Family history present in 9.5% of cases

Medication-Related Causes

• Isotretinoin - Associated with increased S. aureus colonization and blepharitis 1
• Dupilumab - Used for atopic dermatitis, associated with blepharitis in 32-55% of patients 1
• Antipsychotics - Both typical and atypical antipsychotics can cause blepharospasm 6
• Anticholinergic medications - Can exacerbate dry eye and indirectly cause twitching

Red Flags Requiring Further Investigation

• Eye twitching persisting beyond 2-3 weeks
• Progressive worsening of symptoms
• Development of additional ocular or neurological symptoms
• Bilateral involvement
• Associated ptosis or diplopia
• Symptoms that interfere with daily activities

Diagnostic Approach

1. History assessment:

   • Duration and frequency of symptoms
   • Unilateral vs bilateral presentation
   • Time of day when symptoms worsen
   • Associated symptoms (pain, redness, discharge)
   • Medication review
   • Exacerbating factors (screen time, stress, caffeine)

2. Physical examination:

   • Eyelid margin assessment for signs of blepharitis
   • Evaluation for meibomian gland dysfunction
   • Assessment for ptosis that worsens with fatigue
   • Ocular motility examination
   • Slit-lamp examination to evaluate cornea and conjunctiva

3. Specialized testing (if myasthenia gravis is suspected):

   • Ice pack test (place ice over closed eyes for 2-5 minutes)
   • Rest test
   • Evaluation for Cogan lid-twitch sign
   • Single-fiber electromyography (gold standard for myasthenia gravis)

Management Approach

Management should be directed at the underlying cause:

For Common Benign Causes:

• Reduce digital screen time with regular breaks
• Address stress and fatigue through adequate rest
• Decrease caffeine intake
• Ensure adequate hydration
• Apply warm compresses to affected eye

For Blepharitis:

• Eyelid hygiene with warm compresses and lid scrubs
• Treatment of underlying meibomian gland dysfunction
• Anti-inflammatory therapy if indicated

For Medication-Induced Cases:

• Review and potentially modify medication regimen
• Consider alternative medications with lower risk of ocular side effects

For Myasthenia Gravis:

• Pyridostigmine (Mestinon) as first-line treatment
• Corticosteroids for symptom management
• Thymectomy if thymoma is present

For Benign Essential Blepharospasm:

• Botulinum toxin injections (first-line treatment) 4, 5
• Oral medications for symptom control
• Surgical myectomy in refractory cases

Common Pitfalls to Avoid

• Dismissing persistent eye twitching as merely stress-related without proper evaluation
• Failing to recognize the association between digital screen time and eyelid myokymia
• Missing the diagnosis of ocular myasthenia gravis, which can precede generalized myasthenia in 50-80% of cases
• Overlooking medication side effects as potential causes
• Not addressing underlying blepharitis or dry eye syndrome

Remember that while most cases of eye twitching are benign and self-limiting, persistent symptoms warrant thorough evaluation to rule out serious underlying conditions.