Hemi-facial spasm (HFS) has a presentation of variable severity but is consistently troublesome for the affected individual who can suffer significant social embarrassment from the persistent and unpredictable facial twitching. Here, we present a case of a 62-year-old male with a 17-year history of left hemi-facial spasm secondary to compression of the facial nerve at the root exit zone by an ectatic ipsilateral posterior inferior cerebellar artery. His HFS failed neurosurgical intervention, and medical therapies were found to be ineffective or poorly tolerated. His HFS was noted to be exacerbated on forced eye closure and subsequently it was observed that he was compensating with incomplete eye closure on the affected side. Surgical placement of an upper lid gold weight has significantly diminished the severity and frequency of his HFS symptoms and obviated the need for an orbicularis oculi myectomy.