A Man With Unilateral Eyelid Twitching

C. Robert Bernardino, MD


April 03, 2013

Case Diagnosis

Given the patient's findings, the most likely diagnosis is hemifacial spasm.[1] Hemifacial spasm is differentiated from blepharospasm in that it is unilateral and the spasm will persist during sleep. Unlike in blepharospasm, oral sedatives are usually of no benefit in hemifacial spasm.

Myokymia is typically associated with twitching of 1 eyelid that is induced by ocular irritation, stress, or fatigue. Addressing these issues usually leads to resolution of twitching.

Blepharospasm is a neurologic condition associated with a triad of symptoms: dry eyes, photophobia, and bilateral spasms.[2] Typically, the spasms are centered around the eyes, although they may generalize to the mid- and lower face. In contrast to hemifacial spasm, blepharospasm is a bilateral disease that is diminished or absent during sleep. Neuroimaging is not necessary in blepharospasm. Treatment involves relieving the dry eyes, prescribing FL-41 tinted glasses for photophobia, and administering sedatives or botulinum toxin injections to eliminate the spasms.

Marcus Gunn jaw-winking syndrome, usually seen in the setting of congenital ptosis, is a condition in which mastication causes the upper eyelid to fluctuate in height. It is a dysinnervation syndrome characterized by synkinesis between the pterygoid muscles and the levator muscle.

Systemic Evaluation and Clinical Course

Neuroimaging is recommended in all cases of hemifacial spasm. MRI is the study of choice, focusing on the course of cranial nerve VII. In this patient, MRI of the brain and brainstem did not reveal any abnormalities.

The patient underwent botulinum toxin injections to reduce the spasms.


Hemifacial spasm is a neurologic condition in which one side of the face twitches. The pathogenesis is thought to be irritation along the course of the facial nerve. Therefore, neuroimaging to rule out a mass or narrowing of the skull base foramen is necessary.[3] If imaging is negative, the usual therapy is botulinum toxin injections to dampen the spasms of the offending muscles.[4] Facial nerve decompression is also helpful in patients with compression at a foramen or in whom a blood vessel crosses over and compresses the nerve.