“My child keeps blinking and closing his eye”

Introduction

Excessive blinking is a common reason for children to attend the ophthalmologist. The diagnosis is usually apparent after a careful history and examination. The vast majority of the time, the child will have a blinking tic, or an exacerbation of ocular surface irritation, usually allergic eye disease. Parents are often anxious that these overt, potentially stigmatizing movements could be a sign of more sinister neurological or complex behavioral disorders. The ophthalmologist should quickly determine the need for further systemic assessment or investigation, and if possible suggest a simple treatment strategy for the family.

What is the role of the ophthalmologist?

• 1.

  Eliminate any ocular surface disease component as a cause or contributor to blinking.

• 2.

  Exclude monocular closure in intermittent exotropia.

• 3.

  Initiate discussion regarding tic disorders where appropriate.

As a first step in making a diagnosis, the ophthalmologist first needs to exclude any serious ocular cause of irritation which could be the primary cause of the blinking behavior. Ocular irritation may precipitate a bout of blinking from an alternative etiology, such as a tic. The comprehensive ophthalmological examination will exclude any significant ocular allergy, glaucoma, or keratitis, as well as eliminating intermittent exotropia as a reasonably common cause of monocular closure. Coats et al. found vision-threatening ocular disorders in 6 of 99 children with excessive blinking. These included trichiasis, foreign bodies, keratitis, and acute microbial keratitis, conditions which should be obvious from a careful ocular examination. Here, blinking is simply a reaction to the ocular irritation. The overlap between ocular allergy and tic disorders, frequently seen in the same age group, is more subtle. The ocular allergy may be a primary cause of blinking, or a part contributor to episodic exacerbations of the blinking tic. Zhao et al. examined 578 children presenting with “excessive blinking” over a 2-year period. The majority had signs of ocular surface dysfunction, with the largest group (48.95%) having allergic eye disease; 3.99% had a tic disorder. Given the high proportion of allergic eye disease in children presenting with excessive blinking, a trial of a preservative-free mast cell stabilizer, such as topical ketotifen or olopatadine may be helpful.

Once the ophthalmologist has excluded ocular surface disease, uncorrected refractive error and intermittent exotropia, then the likely diagnosis is an eyelid blinking tic. In a prospective, consecutive case series of 99 children presenting with excess blinking, Coats et al. found an underlying etiology that would be discovered by a standard comprehensive ophthalmological examination in 62%. Anterior segment and/or lid abnormalities were the underlying cause in 37% of children, uncorrected refractive errors in 14%, and intermittent exotropia accounted for 11%. Tic disorder accounted for 33% of children. Vrabec et al. found a temporally related stressful event, which coincided with the onset of the blinking, in 41% of children they classified as “functional blinking.” Other authors have shown a much higher proportion of tic disorder in children presenting with frequent eye blinking. Jung and co-workers prospectively examined a series of 50 children with frequent eye blinking, excluding children with refractive error, intermittent exotropia or lid disorders: 86% were diagnosed with a tic disorder, with 78% being transient tic disorder. Seven out of the 50 children had ocular surface disease, mostly allergic conjunctivitis.