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. 1

First-Line Treatment: Botulinum Toxin Injections

Botulinum Toxin Options

• IncobotulinumtoxinA (Xeomin): FDA-approved for blepharospasm with demonstrated efficacy in both treatment-naïve and previously treated patients 2

  • Typical dosing: 25-50 Units total (median of 33 Units per eye)
  • Common injection sites: temporal area, eyebrow area, upper lid, lower lid, and orbital rim 2
  • Duration of effect: typically 12-14 weeks

• OnabotulinumtoxinA (Botox): Similar efficacy to Xeomin 1

• AbobotulinumtoxinA (Dysport): May be effective but has less supporting evidence 1

Important note: Dosing units of botulinum toxins are NOT interchangeable between commercial products 2

Conservative Management Options

For mild cases or as adjunctive therapy:

• Warm compresses: Apply for 10-15 minutes, 1-2 times daily 1
• Gentle eyelid cleansing: To remove crusting from eyelashes 1
• Commercial eyelid wipes: May be considered, though evidence for superiority over simple warm compresses is limited 1

Pharmacological Management

For addressing underlying or contributing conditions:

• Short-term topical corticosteroids: Such as loteprednol etabonate for acute inflammation 1
• Topical cyclosporine: For posterior blepharitis that may contribute to blepharospasm 1
• Topical antibiotics: Including bacitracin or erythromycin ointment for associated anterior blepharitis 1
• Oral antibiotics:
  • Doxycycline, minocycline, or tetracycline for cases with associated meibomian gland dysfunction 1
  • Azithromycin (with caution in patients with cardiovascular problems) 1

Protective Measures

• Bandage contact lenses or scleral lenses: Can shield corneal nociceptors in blepharospasm patients 1

Treatment Considerations and Pitfalls

Special Patient Populations

• Patients with advanced glaucoma: Avoid aggressive pressure during eyelid massage to prevent complications 1
• Patients with neurotrophic corneas: Require careful counseling to avoid corneal epithelial injury 1

Botulinum Toxin Side Effects

• Common side effects include:
  • Drooping eyelid (ptosis) (23.3%) 3
  • Dry eye (18.1%) 3
  • Tearing (5.5%) 3
  • Strabismus (1.4%) 3
  • Corneal injury due to reduced blinking 2

Treatment Duration and Response

• Approximately 90% of patients benefit from botulinum toxin treatment 4
• Effect typically lasts 14-17 weeks before requiring repeat injections 3
• Patients with blepharospasm may require more frequent treatments than those with hemifacial spasm 5

Treatment Algorithm

1. Initial Assessment: Confirm diagnosis of blepharospasm
2. First-line: Botulinum toxin injections (Xeomin or Botox)
3. Adjunctive therapy: Conservative measures (warm compresses, eyelid hygiene)
4. For associated conditions: Add appropriate topical or oral medications
5. Follow-up: Schedule repeat injections when symptoms recur (typically 3-4 months)
6. For inadequate response: Consider adjusting dose or injection technique

While there is no cure for blepharospasm, the available treatment options effectively manage the signs and symptoms of the condition 6, with botulinum toxin injections providing relief in approximately 90% of cases 4.