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Eyelid Myokymia
Article Last Updated: Nov 1, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Byron L Lam, MD, Department of Ophthalmology, Professor, Bascom Palmer Eye Institute, University of Miami School of Medicine
Byron L Lam is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, and Phi Beta Kappa
Editors: Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
eyelid twitching, eyelid jumping, muscle contractions, blepharospasm, Meige syndrome, hemifacial spasm, spastic-paretic facial contracture, botulinum toxin A, BOTOX®, BOTOX® injections
Background
Myokymia is the spontaneous, fine fascicular contractions of muscle without muscular atrophy or weakness. Eyelid myokymia typically involves the orbicularis oculi muscle of one of the lower eyelids; occasionally, the upper eyelids also can be affected. In most cases, eyelid myokymia is benign, self-limited, and not associated with any disease. Intervention is seldom necessary. Rarely, eyelid myokymia may occur as a precursor of blepharospasm, Meige syndrome, hemifacial spasm, and spastic-paretic facial contracture.
Pathophysiology
The pathophysiology of typical eyelid myokymia is not well understood. The focus of irritation is most likely the nerve fibers within the muscle. However, pontine dysfunction in the region of the facial nerve nucleus also has been implicated. Possible precipitating factors include stress, fatigue, and excessive caffeine or alcohol intake.
Frequency
United States
The incidence and prevalence of eyelid myokymia are unknown, but symptoms of eyelid myokymia are not infrequently encountered in the ophthalmic clinic.
Mortality/Morbidity
Eyelid myokymia is a benign and self-limited condition in most patients.
Age
Eyelid myokymia may occur at any age.
History
- Patients with eyelid myokymia usually note sporadic "jumping" or "twitching" of one of the lower eyelids. The upper eyelids also can be involved. The irregular contractions are usually unilateral and may occur intermittently for days to months.
- In rare cases, the contractions may be severe enough to move the eye to produce oscillopsia.
- A history of stress, fatigue, and excessive caffeine or alcohol intake may be present.
Physical
- Fine contractions of the orbicularis oculi may be visible, if the patient has the contractions during examination.
- If present, the contractions are usually intermittent and are more apparent to the patient than to the observer.
- The symptoms often improve when the eyelid is pulled manually.
- Rarely, the contractions may be vigorous enough to cause movement of the globe, producing fine nystagmuslike eye movements.
- If the eyelid myokymia is associated with contraction of other parts of the face, blepharospasm, Meige syndrome, hemifacial spasm, and spastic-paretic facial contracture should be excluded.
Causes
The cause is unknown but may be associated with stress, fatigue, and excessive caffeine or alcohol intake.
Blepharospasm, Benign Essential
Other Problems to be Considered
Meige syndrome - Blepharospasm and oral facial dystonia
Hemifacial spasm - Unilateral facial contraction due to seventh nerve dysfunction
Spastic-paretic facial contracture - Unilateral tonic facial contracture due to pontine dysfunction, associated usually with multiple sclerosis, and brainstem tumors or vascular lesions
Imaging Studies
- Brain magnetic resonance imaging (MRI) is not needed for typical eyelid myokymia but should be considered if facial myokymia, hemifacial spasm, or spastic paretic facial contracture is suspected.
Medical Care
- Reassurance and reduction in precipitating factors, if identifiable, are appropriate for most patients.
- Treatment is usually not needed except when symptoms are severe or when oscillopsia is present.
- Local subcutaneous botulinum toxin A (BOTOX®) injections of 2.5-5 units each to the affected eyelid region provide relief for 12-16 weeks. If the upper eyelid is involved, the injections should not be placed near the levator palpebrae; otherwise, ptosis lasting weeks will result.
- Adverse effects include temporary lid laxity, which may produce lagophthalmus, exposure keratopathy, and ptosis.
- The efficacy of other agents has not been proven.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Toxins
May inhibit transmission of impulses in neuromuscular tissue.
| Drug Name | Botulinum toxin A (BOTOX®) |
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| Description | Blocks neuromuscular conduction by binding to receptor sites on motor nerve terminals, entering the nerve terminals and inhibiting the release of acetylcholine. One treatment is usually sufficient, but in persistent cases, the injection may be repeated in 4-6 mo. Injection should be used only when symptoms are severe or when oscillopsia is present. Treatment of pediatric patients is not recommended. |
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| Adult Dose | Local injections of 2.5-5 U each to affected eyelid region |
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| Pediatric Dose | Not recommended |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects of botulinum toxin |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Injections of the upper lids may produce ptosis, which may last for weeks; do not exceed recommended dosages and frequencies of administration; presence of antibodies to botulinum toxin type A may reduce effects of therapy |
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Further Outpatient Care
- Rarely, eyelid myokymia may occur as a precursor of blepharospasm, Meige syndrome, hemifacial spasm, facial myokymia, and spastic-paretic facial contracture.
- Advise patients to return for reexamination, if there is a change in symptoms.
Deterrence/Prevention
- If precipitating factors can be identified, avoidance will reduce the frequency of episodes.
Prognosis
- Prognosis is excellent in most cases.
Patient Education
Medical/Legal Pitfalls
- Note that persistent myokymia followed by spastic paretic facial contracture is an important (although uncommon) sign of disease in the dorsal pons, which may be seen in multiple sclerosis and brainstem neoplasms or vascular lesions.
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- Krohel GB, Rosenberg PN. Oscillopsia associated with eyelid myokymia. Am J Ophthalmol. Nov 15 1986;102(5):662-3. [Medline].
- Lowe R. Facial Twitching. Trans Ophthalmol Soc Aust. 1951;11:129-133.
- Reinecke RD. Translated myokymia of the lower eyelid causing uniocular vertical pseudonystagmus. Am J Ophthalmol. Jan 1973;75(1):150-1. [Medline].
- Rubin M, Root JD. Electrophysiologic investigation of benign eyelid twitching. Electromyogr Clin Neurophysiol. Sep 1991;31(6):377-81. [Medline].
- Scott AB. Botulinum toxin for blepharospasm. In: Spaeth G, Katz LJ, Parker KW, eds. Current Therapy in Ophthalmic Surgery. Toronto: Decker;1989:322-324.
- Sogg RL, Hoyt WF, Boldrey E. Spastic paretic facial contracture. A rare sign of brain stem tumor. Neurology. Jul 1963;13:607-12. [Medline].
Eyelid Myokymia excerpt Article Last Updated: Nov 1, 2006
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