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The Prevalence of Eyelid Myokymia in Medical Students

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Aims: To determine the prevalence and factors associated with eyelid myokymia (EM) in students attending Medical faculty. Study Design: Cross sectional survey. Place and Duration of Study: Medical faculty University of Tuzla and Department of Ophthalmology University Clinical Centre Tuzla, between December 2015. and January 2016. Methodology: We included 100 medical students, randomly selected by staff employed in student service of Medical faculty, from the list of students registered for different exams in December 2015. Before the survey all participants were informed about the signs and presentations of eyelid twitching and its possible significance. The survey was performed before and after the exams with students of third, fourth and fifth study year. It consisted of 18 questions regarding the presence of eyelid twitch, and influence of various factors on its frequency and intensity. Results: Forty four percent of students had signs of eyelid myokimia (EM) during short period of 7 days before the exams. Female students were more likely to have EM than male students (OR 2.46:1). Students of fifth study year were at more risk for development of EM than students of fourth and third year respectively (OR 1:1.5:2.67). Energy drinks consuming was a significant predictor for EM occurrence (P=.046). Students who reported to have reduced sleep during exam preparation have significantly more often symptoms of EM (P=.014) as well as individuals who claim to have been exposed to a greater amount of stress (P=.042). Conclusion: Eyelid myokymia is relatively common phenomenon among students of Medical faculty. It has higher incidence before exams, during the period of intense studying.
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*Corresponding author: E-mail: zvornicanin_jasmin@hotmail.com;
British Journal of Medicine & Medical Research
14(6): 1-6, 2016, Article no.BJMMR.24910
ISSN: 2231-0614, NLM ID: 101570965
SCIENCEDOMAIN international
www.sciencedomain.org
The Prevalence of Eyelid Myokymia in Medical
Students
Sanela Hadžić
1
, Ismir Kukić
1
and Jasmin Zvorničanin
2*
1
Faculty of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina.
2
Department of Ophthalmology, University Clinical Centre Tuzla, Bosnia and Herzegovina.
Authors’ contributions
This work was carried out in collaboration between all authors. All authors have made substantial
contributions to conception and design of the study. Authors SH and IK were involved in the data
acquisition while authors SH and JZ participated in the data interpretation. All authors were involved in
literature search and writing the article. Authors SH and JZ drafted the manuscript and made the
critical revision. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/BJMMR/2016/24910
Editor(s):
(1) Barbara Giambene, Eye Clinic, Department of Translational Surgery and Medicine, University of Firenze,
Italy.
Reviewers:
(1)
C. O. Adeoti, Ladoke Akintola University of Technology teaching hospital, Osogbo, Nigeria.
(2)
Seydi Okumus, Gaziantep University Medical School, Turkey.
(3)
Sagili Chandrasekhara Reddy, National Defence University of Malaysia, Malaysia.
Complete Peer review History:
http://sciencedomain.org/review-history/13719
Received 8
th
February 2016
Accepted 2
nd
March 2016
Published 16
th
March 2016
ABSTRACT
Aims: To determine the prevalence and factors associated with eyelid myokymia (EM) in students
attending Medical faculty.
Study Design: Cross sectional survey.
Place and Duration of Study: Medical faculty University of Tuzla and Department of
Ophthalmology University Clinical Centre Tuzla, between December 2015. and January 2016.
Methodology: We included 100 medical students, randomly selected by staff employed in student
service of Medical faculty, from the list of students registered for different exams in December
2015. Before the survey all participants were informed about the signs and presentations of eyelid
twitching and its possible significance. The survey was performed before and after the exams with
students of third, fourth and fifth study year. It consisted of 18 questions regarding the presence of
eyelid twitch, and influence of various factors on its frequency and intensity.
Short Research Article
Hadžić et al.; BJMMR, 14(6): 1-6, 2016; Article no.BJMMR.24910
2
Results: Forty four percent of students had signs of eyelid myokimia (EM) during short period of 7
days before the exams. Female students were more likely to have EM than male students (OR
2.46:1). Students of fifth study year were at more risk for development of EM than students of
fourth and third year respectively (OR 1:1.5:2.67). Energy drinks consuming was a significant
predictor for EM occurrence (P=.046). Students who reported to have reduced sleep during exam
preparation have significantly more often symptoms of EM (P=.014) as well as individuals who
claim to have been exposed to a greater amount of stress (P=.042).
Conclusion: Eyelid myokymia is relatively common phenomenon among students of Medical
faculty. It has higher incidence before exams, during the period of intense studying.
Keywords: Eyelid twitching; stress; eyelid myokymia; blepharospasm.
1. INTRODUCTION
Myokymia consists of involuntary, fine and
undulating fascicular contractions that spread
across the affected striated muscle [1,2]. Eyelid
myokymia (EM), also called benign eyelid twitch,
is a fine fasciculation (tiny muscle contractions)
generally affecting one eyelid (more often a lower
eyelid, but upper eyelids as well). It does not
involve upper and lower eyelids on the same
side, or eyelids on both side of the face at the
same time and rarely involve more than one
eyelid at different times. Twitching is episodic,
lasting seconds to hours over minutes to months,
but always eventually resolves on its own [3].
Unlike facial myokymias, those limited to the
eyelid only tend to appear in healthy young
subjects [2,4]. They present in healthy subjects
with no associated diseases and are associated
with stress, fatigue, exercise and excessive
caffeine use [1,2,4,5]. Although benign in its
nature, EM can be one of signs of systemic
disorders such as multiple sclerosis [2,6],
subarachnoid haemorrhage [7], intracranial
tumours [8], cysticercosis [9], multiple system
atrophy and Guillain-Barré syndrome [1,2,10,11].
Eyelid twitching is also a sign of other more
localized disorders, such as benign essential
blepharospasm, Meige syndrome, tardive
dyskinesia, hemifacial spasm, facial nerve injury
with aberrant regeneration, blepharoptosis and
secondary blepharospasm [3]. It is important to
note, that EM can be associated with use of
several drugs, such as flunarazine, clozapine
and topiramate [4].
The purpose of this survey was to determine the
prevalence and factors associated with EM in
students attending Medical Faculty University of
Tuzla.
2. MATERIALS AND METHODS
We performed a cross sectional survey on 100
medical students of Medical faculty University of
Tuzla. The students were randomly selected by
staff employed in student service of Medical
faculty, from the list of students registered for
different exams in December 2015. The survey
was performed before and after the exams in
students of third, fourth and fifth study year. All
students included in this survey were interviewed
for previous history of possible systemic,
especially neurologic or chronic ophthalmic
diseases, in order to be considered as healthy
subjects. Students with previous history of
neurologic or any other systemic disorders were
excluded from this survey. Also students with
previous history of any chronic eye disease or
trauma were also excluded from this survey.
Before the survey all participants were informed
about the signs and presentations of eyelid
twitching and its possible significance. The
survey consisted of 18 questions regarding the
presence of eyelid twitch, and influence of
various factors on its frequency and intensity,
such as: Age, gender, year and duration of study,
sleep deprivation, smoking status, usage of
caffeine and different energy drinks, intensity of
learning and preparation for the exam, number
and difficulty of the exams they are taking and
overall stress they are exposed during the study.
To assess the level of stress and anxiety, we
used The Westside Test Anxiety Scale (WTAS).
The Westside Test Anxiety Scale is brief
screening instrument meant to identify students
with anxiety impairments. The scale is comprised
of ten items, and takes about five to eight
minutes to administer. It combines six items
assessing performance impairment, four items
on worry and dread, and no items on
physiological over-arousal. The students are
asked to rate on 5 point scale, how true is each
Hadžić et al.; BJMMR, 14(6): 1-6, 2016; Article no.BJMMR.24910
3
of the 10 statements. The sum of all 10 questions
is divided by 10 and provides average grade of
stress and anxiety impairment [12].
Statistical analyses were performed using Stata
Statistical Software, version 13.0 (StataCorp LP,
College Station, Texas, USA) and SPSS for
Windows, version 20.0 (IBM-SPSS, Chicago, IL,
USA). Confidence intervals and P values were
calculated at the P ˂ 0.05 level. Pairwise
interactions between regression model variables
were associated simultaneously using a Wald F
test and considered significant at P ˂ 0.10 level.
The current survey was approved by the Medical
faculty authorities and adhered to the tenets of
the Declaration of Helsinki. Informed consent
was obtained from all participants included in this
survey.
3. RESULTS AND DISCUSSION
3.1 Results
This survey included 100 students of Medical
faculty University of Tuzla. The survey
participants were: 50 students of third, 30
students of fourth and 20 students of fifth study
year. Average age of participants was
22.92±2.45 years (range 20 to 34), while average
duration of Medical faculty studying was
4.99±2.83 years (range 3 to 15 years). There
were 72 (72%) of female and 28 (28%) of male
students equally distributed over the studying
years (P = .672). Of 100 included students 44
(44%) had present EM during short period of 7
days before the exams. Thirty seven out of 72
(51.4%) female students and 7 out of 28 (25%)
male students had positive signs of EM, where
female students were significantly more likely to
have EM than male students (P = .05;
OR: 2.46:1).
The prevalence of EM in students of third, fourth
and fifth study year was 28%, 50% and 75%
respectively. Students of fifth study year were at
more risk for development of EM than students of
fourth and third year (P = .01; OR: 1: 1.5: 2.67)
(Diagram 1.). Length of studying was not
statistically significant predictor for EM
development (P = .372). Side, right of left, was
not correlated with EM development (P = .246),
while previous history of allergic conjunctivitis
was correlated (P = .01). Regular distributed
learning and more intensive (campaign) learning
were not significant predictors for EM occurrence
either (P = .505). Seventy seven per cent of
students stated they regularly drink coffee and
16% were smokers. Coffee intake and smoking
status were not statistically correlated with EM
development (P = .310 and P = 0.568). However,
39% of students consume energy drinks, which
was a significant predictor for EM occurrence
(P = .046). Alcohol intake during preparation and
after the exams was present in 52% of students
and was not correlated with signs of EM
development (P = .065).
Diagram 1. The prevalence of EM in students
of third, fourth and fifth study year
The average value of WTAS before the exams
was 3.98±0.95 while after the exams it was
2.43±0.99. Before the exams 71 (71%) of
students had extremely high anxiety, while after
the exams this number reduced to 12 (12%).
Subjective evaluation of stress, to which students
of Medical faculty are exposed, showed that
students who claim to have been exposed to a
greater amount of stress have more often
symptoms of EM (P = .042). Additionally,
students who reported to have reduced sleeping
during exam preparation have significantly more
often EM occurrence (P =.014).
After finishing exams and a short break, out of
44% of students with earlier positive EM
symptoms, 10% had decreased incidence of
twitching, while in 34% of students it completely
disappeared. Symptom reduction was not related
to participants gender (P = .553), age
(P = .103), year of study (P = .101), duration of
studying (P = .342), side of EM (P = .423),
campaign learning (P = .687), coffee intake
(P = .303), smoking status (P = .585), energy
drink consuming (P = .452), alcohol intake (P =
.153), subjective stress assessment (P = .218)
and sleeping reduction (P = .71).
Hadžić et al.; BJMMR, 14(6): 1-6, 2016; Article no.BJMMR.24910
4
3.2 Discussion
The present survey shows that 44% of students
attending third, fourth and fifth year of Medical
faculty have certain signs of EM. Female
students have 2.6 times more chances for
developing EM symptoms than males.
Other local factors, such as previous history of
allergic conjunctivitis, as well as factors related to
behaviour and habits, such as consuming
of energy drinks, are related to EM occurrence.
Advancement of studying, as well as
sleep deprivation and self-assessed higher level
of stress, are also positive predictors for
EM development. On the other side, EM
reduction after the exams is not statistically
correlated to any of the predisposing factors
for its development. Cessation of exam
anticipation together with reduction of learning
activities, probably reduce the amount of stress,
and can be considered as a factors for EM
waning. In our survey, after short brake of 7
days, with return to regular daily activities, EM
frequency reduces and in most cases completely
disappears.
Eyelid myokymia is regularly seen in healthy
young subjects with no associated diseases and
is associated with stress, fatigue, exercise, and
excessive caffeine use [1,2,4,5]. Stress is an
important factor in the educational process, and
teaching together with learning are stressful
processes [13]. The prevalence and level of
unfavourable stress and depression during
medical training is significantly higher than before
the onset medical training [14]. Medical students
are more anxious than general population, with
prevalences of 7.7 - 65.5% for anxiety, 6.0 -
66.5% for depression and 12.2 - 96.7% for
psychological distress [15]. The relationship
between teachers and students is an effective
factor in all dimensions of clinical education
stressors [13]. Results of this survey are in
accordance with these findings, with emphasis
on reduced sleeping and energy drink consuming
as factors that enhance the effect of stress which
students are exposed during exam preparation.
Eyelid myokymia prevalence of 44% is relatively
high, but it is difficult to determine the absolute
value of these results due to lack of data from
other studies which could be comparable. These
data suggest that more research is needed to
explore the potential causal links between EM,
stress and depression during medical faculty
training.
When taking into account symptoms of twitching,
man has to be aware that benign eyelid
myokymia (eyelid twitching) can also be a sign of
other more serious disorders. Benign essential
blepharospasm may also start as pronounced
eyelid twitching, with sudden (overnight) or more
insidious onset (starting as a “twitch” in one
eyelid or spasms of both the upper and
lower eyelids on one side). This onset variability
may sometimes pose considerable confusion
early on in the disorder [3]. Other clinical entities
with much more serious clinical presentation
and prognosis include: Meige syndrome, tardive
dyskinesia, hemifacial spasm, facial nerve injury
with aberrant regeneration, blepharoptosis
and secondary blepharospasm [3]. These
disorders include eyelid twitching with
simultaneous involuntary spasms or writhing
movements of the mid-face, and possibly
extending down into the neck, writhing
movements of the tongue, mouth, or lips in
isolation [3]. Treatment options of essential
blepharospasm and hemifacial spasm, as well as
other twitching disorders, include more options
where most recent studies provide sufficient
evidence for the safety profile of
AbobotulinumtoxinA for both, blepharospasm
and hemifacial spasm [16].
Eyelid twitches are rarely considered to be
serious health problem that requires medical
treatment, but certain signs need to alert one to
see a doctor: if an eye is red, eyelid is swollen, or
has an unusual discharge (eyelid completely
closes each time), upper eyelid is drooping,
eyelid twitching continues for several weeks even
months, eyelid twitching is more frequent than
usual and occur on both sides of the face and if
the twitching begins affecting parts of the whole
face. These sings need to be evaluated by a
medical professional in order to determine
possible need for further systemic investigation
[17].
This study has also certain limitations regarded
to subjective evaluation and reporting of EM
symptoms and overall stress. However,
our participants are medical students, which all
had been informed about EM symptoms and
presentation before taking the survey, in order to
minimise the risk of over-reporting the
EM symptoms. Nevertheless, this is small cohort
of 100 students, and we included only 20% of
whole student population from third, fourth
and fifth study year. On the other side, this is
a first survey of this kind in our region that
provides certain information for somatic
Hadžić et al.; BJMMR, 14(6): 1-6, 2016; Article no.BJMMR.24910
5
presentation of stress in medical students.
Further research is needed in order to acquire
adequate information about EM in medical
students and its correlation with behavioural
factors as well as possible long term
consequences for general health.
4. CONCLUSION
An eyelid myokymia is relatively common
phenomenon among students of Medical faculty.
It has higher incidence before exams, during the
period of intense studying. Female students were
generally more frequently affected, and the
incidence of twitching was increasing with
advancement of studying in both male and
female students. Eyelid twitches are rarely
serious enough to require medical treatment, but
if they are frequent and occur on both sides of
the face it is recommended to make a detailed
ophthalmic and neurological examination.
ACKNOWLEDGEMENT
The authors would like to thank all their
colleagues who participated in this survey.
This results of this survey were partly presented
by Sanela Hadžić, Ismir Kukić, Alija Numanović,
Admira Karić and Enita Šako, mentor Jasmin
Zvorničanin “Eyelid twitch” in 2nd SaMED -
International medical students' congress in
Sarajevo, Bosnia and Herzegovina, February, 4-
6, 2016.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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_________________________________________________________________________________
© 2016 Hadžić et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Peer-review history:
The peer review history for this paper can be accessed here:
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... Such a problem can be solved by fixing sleep schedules and hours, using eye drops for dry eyes, and most importantly regulating caffeine consumption if it is exceeding the acceptable safety levels. 44 ...
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Article
Characteristically continuous facial myokymia is a pathognomonic, exceedingly rare physical sign of intrinsic brain-stem lesions e.g. multiple sclerosis (where the myokymia lasts only for a few months), pontine glioma (where it is unremitting for years). The physiopathogenesis is unclear. Electromyographic patterns are characteristic. Therapy and prognosis are related to the basic aetio-pathological process. Only two out of 132 cases of intrinsic brain-stem lesions in the department of Neurosurgery, Seth G.s. Medical College, Bombay over a period of 3 decades, exemplify its rarity. These two cases are reported here and the relevant literature is reviewed.
A 48 year old woman presented with a 5 year history of intermittent right eyelid twitching. Electromyography of the right lower eyelid revealed myokymic discharges. Blink reflex study revealed a contralateral R1 on stimulating the left, but not the right, supra-orbital nerve. Sensory and auditory evoked potentials were abnormal, pointing to possible brainstem lesions. Oligoclonal bands were present in the cerebrospinal fluid. Magnetic resonance imaging of the brain was normal. This case report demonstrates that benign eyelid twitching can be a localized form of facial myokymia and may be a manifestation of underlying brainstem disease.