Blepharospasm testing includes which of the following?

• A. NaFl and TBUT
• B. TBUT and MRI
• C. NaFl, TBUT, and MRI if twitching persists during sleep
• D. NaFl, TBUT, and gonioscopy

Answer: (C)

Blepharospasm evaluation starts with checking the ocular surface and tear film because irritation and surface disease can trigger or worsen eyelid spasms. Sodium fluorescein staining shows corneal or conjunctival damage, while tear breakup time assesses tear film stability. These help determine if the spasms are being amplified by ocular surface irritation.

Imaging is considered when the twitching persists into sleep. Primary blepharospasm typically diminishes with sleep, so if spasms continue during sleep, it raises concern for an organic neurological issue and warrants MRI to look for central causes. If twitching stops with sleep, MRI is not routinely needed. Gonioscopy isn’t part of blepharospasm testing since it’s a glaucoma-focused procedure and not relevant to evaluating eyelid dystonia.

So the best approach combines NaFl, TBUT, and MRI only if twitching persists during sleep.