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!


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)…



Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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