What is the appropriate management for a patient with sudden onset of unilateral blepharospasm (inability to blink in one eye) and mild irritation in the other eye?

Sudden Unilateral Facial Nerve Palsy (Bell's Palsy) with Lagophthalmos

Your patient has acute unilateral facial nerve palsy (likely Bell's palsy) causing lagophthalmos (inability to close the affected eye), which requires immediate aggressive ocular surface protection to prevent exposure keratopathy and potential vision loss.

Immediate Assessment Priorities

Confirm the diagnosis by examining for:

• Complete inability to close one eyelid voluntarily (lagophthalmos), not blepharospasm 1
• Facial asymmetry with forehead involvement (distinguishes peripheral from central lesion) 1
• Loss of nasolabial fold on affected side 1
• Corneal exposure with fluorescein staining to assess epithelial damage 2
• Bell's phenomenon (eye rolls upward when attempting to close) - protective if present 1

Rule out serious neurological causes immediately:

• Check for other cranial nerve deficits (especially III, IV, VI) - if present, requires urgent neuroimaging 1, 3
• Assess for signs of increased intracranial pressure or meningeal irritation 1
• In elderly patients, evaluate for temporal tenderness, jaw claudication, or scalp pain suggesting giant cell arteritis 1, 3

Urgent Ocular Surface Protection

The affected eye cannot blink and is at immediate risk for exposure keratopathy, corneal ulceration, and permanent vision loss. 2

First-Line Protective Measures:

Aggressive lubrication protocol:

• Preservative-free artificial tears every 1-2 hours while awake 2
• Thick lubricating ointment (e.g., erythromycin or bacitracin ophthalmic ointment) at bedtime and frequent daytime application 2
• Consider moisture chamber goggles or protective eyewear during the day 2

Nighttime eye protection is critical:

• Tape the eyelid closed at night using hypoallergenic surgical tape or eye patches 2
• Apply thick ointment before taping 2
• Some patients benefit from moisture chambers or swimming goggles at night 2

Monitor for Corneal Complications:

Examine daily for the first week, then every 2-3 days:

• Fluorescein staining to detect epithelial defects 2
• Signs of corneal infiltrates, ulceration, or infection 2
• Worsening irritation symptoms suggesting progressive exposure 2

Treatment of the Underlying Facial Palsy

While ocular protection is your immediate priority, coordinate with neurology or primary care for:

• Systemic corticosteroids (prednisone 60-80mg daily) if initiated within 72 hours of onset 1
• Consider antiviral therapy (acyclovir or valacyclovir) in combination with steroids 1
• Rule out Lyme disease, herpes zoster (Ramsay Hunt syndrome), or other infectious causes 1

Addressing the Contralateral Eye Irritation

The "slightly irritated" other eye likely represents:

• Compensatory overuse from increased blinking to protect the affected eye 4
• Reflex tearing or dry eye from disrupted blink dynamics 4
• Possible bilateral blepharitis that may have preceded or been unmasked by the acute event 2

Management:

• Examine for blepharitis signs (lid margin inflammation, meibomian gland dysfunction, crusting) 2
• If blepharitis present: warm compresses and lid hygiene with diluted baby shampoo or commercial lid cleaners 2
• Supplemental artificial tears for symptomatic relief 2

Critical Pitfalls to Avoid

Do not confuse this with blepharospasm (involuntary eyelid closure/spasm), which is the opposite problem - blepharospasm causes excessive blinking and forced eye closure, not inability to blink 5, 6. Your patient cannot close the eye at all, indicating facial nerve palsy.

Never delay corneal protection - exposure keratopathy can develop within 24-48 hours and progress to ulceration, perforation, and permanent vision loss 2. The inability to blink removes the primary mechanism for tear distribution and corneal protection.

Do not assume benign etiology without proper evaluation - while Bell's palsy is most common, serious causes including stroke, tumor, or infection must be excluded, especially if recovery doesn't begin within 3-4 weeks 1, 3.

Expected Timeline and Follow-up

Most Bell's palsy cases begin improving within 3 weeks and recover fully by 3-6 months 1. However, maintain aggressive ocular protection until eyelid closure is restored. If no improvement by 4-6 weeks, neuroimaging (MRI brain with contrast) is indicated to exclude structural lesions 1.

Consider ophthalmology referral if:

• Corneal epithelial defects develop despite aggressive lubrication 2
• No improvement in eyelid function by 3-4 weeks 1
• Progressive vision loss or severe pain develops 2, 3