What are the treatment options for blepharospasm under the eye?

Treatment Options for Blepharospasm Under the Eye

Botulinum toxin injections are the first-line treatment for blepharospasm under the eye, with onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin) being equally effective and should be considered as primary treatment options. 1

First-Line Treatment: Botulinum Toxin Injections

Botulinum toxin works by blocking the release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis that relieves the involuntary spasms characteristic of blepharospasm.

• FDA-approved formulations:

  • IncobotulinumtoxinA (Xeomin) - typically 25-50 units per treatment 2
  • OnabotulinumtoxinA (Botox) - similar efficacy to incobotulinumtoxinA 1
  • AbobotulinumtoxinA (Dysport) - possibly effective but with less evidence 1

• Injection protocol:

  • Common injection sites include the temporal area, eyebrow area, upper lid, lower lid, and orbital rim 2
  • Median dose ranges from 5-13 units per injection site 2
  • Effects typically last 12-16 weeks, requiring repeated treatments 3, 4

• Efficacy:

  • Approximately 87-90% of patients experience total relief of spasms 5, 3
  • Treatment-naïve patients may respond better to higher doses (50 units vs 25 units) 2

• Potential side effects:

  • Transient ptosis (drooping eyelid) - occurs in about 23% of patients 3
  • Dry eyes (18%) 3
  • Tearing (5.5%) 3
  • Strabismus (1.4%) 3
  • Injury to the cornea due to reduced blinking 2

Second-Line and Adjunctive Treatments

For patients who have inadequate response to botulinum toxin or need additional symptom management:

Eyelid Hygiene and Warm Compresses

• Apply warm compresses for 10-15 minutes, 1-2 times daily 6
• Perform gentle eyelid cleansing to remove crusting from eyelashes 1
• Consider commercially available eyelid wipes, though evidence for superiority over simple warm compresses is limited 1

Topical Treatments

• Anti-inflammatory agents:

  • Short-term topical corticosteroids for acute inflammation (e.g., loteprednol etabonate) 1
  • Topical cyclosporine for posterior blepharitis that may contribute to blepharospasm 1

• Antibiotics:

  • Topical antibiotics such as bacitracin or erythromycin ointment for associated anterior blepharitis 1, 6
  • Topical azithromycin for posterior blepharitis 1

Oral Medications

• Antibiotics with anti-inflammatory properties:
  • Doxycycline, minocycline, or tetracycline for cases with associated meibomian gland dysfunction 1, 6
  • Azithromycin (caution in patients with cardiovascular problems) 1, 6

Advanced Options for Refractory Cases

• Protective lenses:

  • Bandage contact lenses or scleral lenses to shield corneal nociceptors 1
  • FL-41 tinted lenses for photophobia 7

• Surgical intervention:

  • Myectomy (surgical removal of portions of the orbicularis oculi muscle) for severe cases unresponsive to botulinum toxin 7

Treatment Algorithm

1. Initial evaluation:

   • Determine if blepharospasm is isolated or part of a more extensive facial dystonia
   • Assess for contributing factors (dry eye, meibomian gland dysfunction, etc.)

2. First-line treatment:

   • Botulinum toxin injections (incobotulinumtoxinA or onabotulinumtoxinA)
   • Start with 25-50 units per eye, divided among multiple injection sites
   • Repeat every 3-4 months as needed

3. For inadequate response:

   • Adjust botulinum toxin dose or injection sites
   • Add eyelid hygiene and warm compresses
   • Consider topical anti-inflammatory agents for associated inflammation

4. For refractory cases:

   • Add oral antibiotics with anti-inflammatory properties
   • Consider protective lenses
   • Evaluate for surgical myectomy if severe and unresponsive to other treatments

Important Considerations

• Patients with advanced glaucoma should avoid aggressive pressure during eyelid massage 6
• Patients with neurotrophic corneas need careful counseling to avoid corneal epithelial injury 6
• The effect of botulinum toxin may be shorter in patients with more severe blepharospasm 3
• Patients with hemifacial spasm typically require lower doses and have longer duration of effect than those with benign essential blepharospasm 4

Botulinum toxin injections remain the cornerstone of treatment for blepharospasm, with high success rates and manageable side effects. A combination approach addressing any underlying ocular surface disease can optimize outcomes and quality of life for affected patients.