Treatment of Eye Blinking Attacks (Blepharospasm)
Botulinum toxin type A injections into the orbicularis oculi muscle are the definitive first-line treatment for blepharospasm, providing rapid relief with sustained benefit lasting 8-14 weeks per treatment cycle. 1, 2, 3
First-Line Treatment: Botulinum Toxin Injections
Botulinum toxin type A is the treatment of choice for blepharospasm, with multiple formulations commercially available (including onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and prabotulinumtoxinA) 3, 4
Most patients (71-89%) achieve normal or near-normal vision restoration after botulinum toxin injections, with beneficial effects appearing rapidly (within days) 2, 1
Treatment effects last an average of 8-9 weeks (8 weeks in men, 9 weeks in women), requiring repeated injections every 3 months to maintain symptom control 2, 5
Injection technique must be tailored to the specific pattern of muscle involvement: standard periocular injections for typical blepharospasm versus selective pretarsal injections for pretarsal blepharospasm 6
Critical Clinical Pattern Recognition
Pretarsal blepharospasm requires selective pretarsal injections rather than standard periocular technique—this subtype presents with impaired eyelid opening, excessive blinking, or spasms of eye closure and can be confirmed by electromyography if clinical suspicion exists 6
Patients with pretarsal blepharospasm who failed standard botulinum toxin injections showed 50% restoration to normal/near-normal vision when correctly treated with pretarsal-specific injections 6
Common Side Effects and Monitoring
Temporary partial ptosis is the most common side effect but is generally well-tolerated by patients 2
Dry eye, reduced blinking, and corneal problems can occur—patients developing eye pain, irritation, photophobia, or visual changes should be referred to an ophthalmologist 5
Serious systemic effects are rare but include dysphagia, respiratory difficulties, and muscle weakness that can occur hours to weeks after injection 5
Second-Line Options When Botulinum Toxin Fails or Is Contraindicated
Pharmacological Alternatives
Oral medications have extremely limited efficacy—in one series, only 1 of 36 patients (3%) responded to medication trials (pimozide after multiple other agents failed) 1
Photochromatic modulation may help manage photophobia symptoms associated with blepharospasm 4
Surgical Management
Eyebrow-eyelid muscle stripping surgery (myectomy) is reserved for patients who fail botulinum toxin or cannot receive repeated injections 1, 4
Surgical outcomes show considerable improvement but with significant complications: frontal anesthesia, exposure keratitis, lagophthalmos, scarring, eyelid malposition, and residual spasm in 50% of cases 1
Patients with prior facial nerve avulsions respond well to botulinum toxin, with 70% achieving normal visual function for an average of 14 weeks 2
Prognostic Factors
Better response to botulinum toxin occurs in: older patients, those with family history of blepharospasm, and those without oromandibular dystonia 2
Poor response occurs with: associated neurological disorders, which should prompt investigation for secondary causes 2
Severity of blepharospasm, duration of symptoms, and history of spontaneous resolution do not predict treatment response 2
Important Clinical Pitfalls
Do not perform extensive etiological investigation in adults with typical primary blepharospasm unless clinical clues suggest a symptomatic cause—the condition is rarely due to identifiable secondary pathology 3
Avoid exceeding recommended dosage and frequency (no more than once every 3 months) to minimize risk of antibody formation and treatment failure 5
Patients previously treated with other botulinum toxin products within 4 months should inform their provider, as cumulative dosing increases risk of systemic effects 5
Caution is required when treating patients with: neuromuscular disorders (myasthenia gravis, Lambert-Eaton syndrome, ALS), respiratory compromise, or swallowing difficulties, as botulinum toxin can precipitate life-threatening complications 5