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Abstract

My patient, a twenty-eight year old woman, presented with a three-week history of constant twitching of her left lower eyelid. She found it distracting and annoying, albeit it did not impair her vision. She had no other ocular symptomatology. Past ocular and medical histories were unremarkable, and she took no medications. She was preoccupied with a toxic divorce, which was traumatizing her eight-year-old son. She noted difficulty falling and staying asleep. Six weeks prior, her internist pronounced her a healthy but stressed woman. My examination revealed left lower orbicularis myokymia, i.e., spontaneous, involuntary twitching of the left lower eyelid. Her ocular examination was otherwise unremarkable, with no signs of foreign body, allergy, or dryness.

Myokymia is usually caused by anxiety and insomnia. I offered her a choice of two highly successful but fundamentally different treatments. Treatment #1 relies on the alternate use of hot packs and ice packs in succession for five minutes, four times a day, along with artificial tears. She was instructed to perform this regimen for one week then report the results directly to me. I assured her that over ninety percent of my patients had success with this intervention; however, I did not know how or why it works. I hypothesized that the temperature differential shocks the muscle and restores normal tone. Treatment #2 relies on the pharmaceutical, botulinum toxin (Botox). Ten micrograms of Botox injected into the lower eyelid will paralyze the twitching muscle within forty-eight hours. The effect lasts three to four months. Potential complications include superficial hemorrhage and a sagging eyelid.

Patients invariably ask what I suggest, often framing the question, "What would you recommend if I were your daughter/mother/father/brother? " In my view, the choice was clear. I suggested trying treatment #1 and holding #2 in reserve. Treatment #1 was cheap, easy, and free from side effects. Treatment #2 had a higher success rate (98%) but was expensive ($300) and riskier. Treatment #1 has been the unanimous selection for over two decades. Treatment #1 is a placebo. There is no scientific basis for its efficacy. In fact, the "shocks the muscle" theory is ipse dixit. Is this good medicine? Did I do the right thing for my patient? Should I have injected Botox into her eyelid and given her "real" medicine? This paper will discuss those considerations.

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