Facial Nerve Palsy and Blepharospasm: Protecting the Eye
Last updated: November 2026
The facial nerve closes the eye. Too little function (facial palsy) exposes the cornea; too much (blepharospasm and hemifacial spasm) can make a patient functionally blind. Both are common and very treatable.
Facial nerve palsy
- Bell palsy: acute, idiopathic lower motor neurone palsy affecting the whole face, including the forehead. Oral prednisolone within 72 hours improves recovery; most patients recover over weeks to months.
- Upper motor neurone (stroke) palsy spares the forehead.
- Other causes: Ramsay Hunt syndrome (zoster, vesicles in the ear), acoustic neuroma surgery, parotid tumour, trauma, Lyme disease, sarcoidosis.
- Red flags for imaging: slow onset, recurrence, other cranial nerve signs, no recovery after 3 months.
Protecting the cornea
| Situation | Treatment |
|---|---|
| All patients | Lubricant drops by day, ointment and taping the lid closed at night, moisture chamber glasses |
| Poor Bell phenomenon, reduced corneal sensation, or keratopathy | Temporary tarsorrhaphy or botulinum-induced ptosis |
| Long-term lagophthalmos | Upper lid loading (gold or platinum weight), lower lid tightening (lateral tarsal strip), medial canthoplasty, brow lift |
Corneal sensation is the key risk factor: palsy with an anaesthetic cornea (for example after acoustic neuroma surgery that also damaged the trigeminal nerve) needs early tarsorrhaphy.
Blepharospasm and hemifacial spasm
| Condition | Features | Treatment |
|---|---|---|
| Benign essential blepharospasm | Bilateral involuntary forceful lid closure, older adults, worse with bright light and stress; may cause functional blindness | Botulinum toxin injections every 3–4 months (first line); dry eye treatment; myectomy in resistant cases |
| Hemifacial spasm | Unilateral twitching of lids and face, persists in sleep; often a vessel compressing the facial nerve root | MRI to exclude a mass; botulinum toxin; microvascular decompression in some |
| Myokymia | Fine twitching of one lid, benign | Reassurance; reduce caffeine, rest |
Where residents slip
- Forgetting nightly lid taping and ointment in facial palsy.
- Missing an anaesthetic cornea in facial palsy after skull base surgery.
- Not imaging hemifacial spasm.
Test yourself: flip cards
Related: Eyelid Malpositions: Entropion, Ectropion, Trichiasis and Chalazion, Third, Fourth & Sixth Nerve Palsies, Tests for Blepharoptosis.
Key sources
- Sullivan FM, et al. Early treatment with prednisolone or acyclovir in Bell palsy. N Engl J Med. 2007;357:1598-1607
- Hallett M, et al. Evidence-based review and assessment of botulinum neurotoxin for the treatment of movement disorders. Toxicon. 2013;67:94-114
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