What causes eye twitching and spasming?

Causes of Eye Twitching and Spasming

Eye twitching (eyelid myokymia) is most commonly caused by stress, fatigue, caffeine consumption, and digital eye strain, but can also indicate underlying conditions like blepharitis, dry eye disease, or in rare cases, neurological disorders such as myasthenia gravis. 1

Common Causes of Eye Twitching

Benign Eyelid Myokymia

• Lifestyle and environmental factors:
  • Stress and anxiety
  • Fatigue and inadequate sleep
  • Excessive caffeine intake
  • Digital eye strain from prolonged screen time
  • Alcohol consumption 2, 3, 4

Ocular Surface Disorders

• Blepharitis and Meibomian Gland Dysfunction (MGD):

  • Inflammation of the eyelid margin
  • Abnormal meibomian gland secretions affecting tear film stability 1

• Dry Eye Disease:

  • Affects tear film stability and ocular surface health
  • Can cause irritation that triggers twitching
  • More common in older adults (prevalence increases from 8.4% in those under 60 to 19.0% in those over 80) 5
  • Higher prevalence in women (16.7%) compared to men (11.4%) 5

Less Common but Serious Causes

Neurological Disorders

• Myasthenia Gravis:

  • Autoimmune disorder affecting neuromuscular junction
  • Causes variable weakness exacerbated by fatigue
  • Ocular myasthenia affects levator, orbicularis oculi, and extraocular muscles
  • Can present with variable ptosis and strabismus 6
  • 50% of patients present with ocular symptoms only, and 50-80% of these develop generalized myasthenia within a few years 6

• Neuropathic Ocular Pain:

  • Dysfunction of nerves that innervate the ocular surface
  • Can develop after ocular surgeries, infections, or chronic ocular surface abnormalities
  • Often described as burning, stinging, or aching
  • May present with photophobia and wind hyperalgesia 6

Medication Side Effects

• Certain medications can cause or exacerbate eye twitching:
  • Antihistamines
  • Antidepressants
  • Antianxiety medications
  • Diuretics
  • Oral corticosteroids 6, 5

Diagnostic Approach

Key Assessment Points

1. Duration and frequency of twitching

   • Brief, self-limiting episodes (days to weeks) typically suggest benign causes
   • Persistent twitching (weeks to months) warrants further investigation

2. Associated symptoms

   • Presence of pain, redness, discharge, or vision changes
   • Bilateral vs. unilateral involvement
   • Accompanying ptosis or diplopia (suggests neurological causes)

3. Specific tests for suspected neurological causes:

   • Ice pack test: application of ice pack over closed eyes for 2-5 minutes may reduce ptosis and misalignment in myasthenia gravis 6
   • Rest test: improvement of symptoms after rest
   • Cogan lid-twitch sign: lid twitch after downward gaze 6, 1

Management Approach

For Benign Eyelid Myokymia

• Lifestyle modifications:
  • Reduce stress through adequate rest
  • Decrease caffeine intake
  • Take regular breaks from digital screens (20-20-20 rule: every 20 minutes, look at something 20 feet away for 20 seconds) 1
  • Ensure adequate sleep

For Ocular Surface Disorders

• Eyelid hygiene:

  • Warm compresses to soften crusting and warm meibomian secretions
  • Gentle massage of eyelids to express meibomian secretions
  • Cleaning eyelid margins with diluted baby shampoo or commercial eyelid cleaner 1

• For dry eye:

  • Artificial tears and lubricants
  • Anti-inflammatory therapy if indicated
  • Tear-conserving strategies 6

For Neurological Causes

• Myasthenia gravis:
  • Pyridostigmine (Mestinon) as first-line treatment
  • Corticosteroids for refractory cases
  • Thymectomy in cases with thymoma or specific age-based and immune-based characteristics 6, 1

Potential Pitfalls

• 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 1
• Overlooking dry eye disease in patients with eye twitching, especially when there's a discrepancy between symptoms and signs 7

When to Seek Medical Attention

• Twitching persists beyond a few weeks
• Twitching affects multiple facial muscles or other body parts
• Eyelid completely closes with each twitch
• Accompanying symptoms include eye redness, swelling, discharge, or vision changes
• Development of ptosis (drooping eyelid) or diplopia (double vision)