Blepharospasm and hemifacial spasm

•The main objective in the treatment of blepharospasm is to decrease or cease the unwanted, repeated forced closure of the eyelids. This is best achieved by the use of botulinum toxin. In a minority of patients, botulinum toxin is either ineffective or poorly tolerated. In this group of patients, a trial with oral medication in the following order is warranted: trihexyphenidyl, baclofen, clonazepam, and tetrabenazine. Before going to the next medication, each of these drugs should be administered at the highest tolerated dosage for a period of 1 or 2 months. If, as often happens, all pharmacologic treatment attempts fail, and the patient is too disabled to remain untreated, he or she can be referred to an experienced plastic surgeon for a myectomy of the eyelid protractors. For treatment of apraxia of eyelid opening, botulinum toxin should be administered as the first treatment. If this fails, and vision is significantly impaired, the patient may be referred to a plastic surgeon for a frontalis suspension of the eyelid.•Treatments of hemifacial spasm are aimed at decreasing or ending the annoying twitches of one side of the face. In this disorder, interference with vision is not a problem unless the contralateral eye is amblyopic. Despite isolated reports of spasm relief by drugs such as carbamazepine, oral medication is unlikely to be helpful. Botulinum toxin is the preferred treatment in hemifacial spasm patients. In some patients, relief from spasms can only be obtained at the cost of an ipsilateral upper lip droop of varying severity. Patients who are dissatisfied with the results of treatment with botulinum toxin, and are not willing to tolerate their condition, can be referred to an experienced neurosurgeon for microvascular decompression of the facial nerve.•Pending success of ongoing attempts to reduce adverse effects, we believe that doxorubicin chemomyectomy, a recent treatment that has been used for both facial spasm and blepharospasm, is best administered in a research setting.