The man who blinked too much
aka Ophthalmology Befuddler 004
The nurse half chuckles and shakes her head as she hands you the next chart. It seems your next patient’s main problem is that he can’t stop blinking!
Questions
Q1. What is blepharospasm?
Answer and interpretation
Uncontrollable blinking as a result of repeated involuntary orbicularis oculi contraction.
It is always bilateral, but may briefly be unilateral at onset. It subsides when asleep.
Q2. What causes blepharospasm?
Answer and interpretation
It is either idiopathic or due to an irritative lesion of the lid or eye (e.g. blepharitis, dry eyes, corneal foreign body).
Q3. What is the differential diagnosis of blepharospasm?
Answer and interpretation
The differentials include a few weird and (not-so-)wonderful conditions:
- hemifascial spasms: idiopathic or a brainstem lesion; may need an MRI
- eyelid myokymia: that funny lower eyelid twitch you get when you’re stressed and tired!
- Tourette syndrome: tics and coprolalia
- Tic doloroux: CN5 distribution pain associated with wincing
- tardive dyskinesia: dyskinesia is not limited to the eyelids
- apraxia of eyelid opening: e.g. Parkinsons; there is no muscle spasm, instead there is failure to voluntarily open the eyes
Q4. How is blepahrospasm treated?
Answer and interpretation
Treatment of the underlying cause is the mainstay, but severe cases may need botox injections or surgery. If there is no obviously correctable cause, it may be time to call one of your friendly ophthalmology colleagues (again)…
References
- Ehlers JP, Shah CP, Fenton GL, Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease Lippincott Williams & Wilkins
- NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide. [Free PDF]
OPHTHALMOLOGY BEFUDDLER
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC