Lagophthalmos (Incomplete Eyelid Closure)

What happens in lagophthalmos

Blinking spreads tears over the eye and closing the eyelids during sleep stops the surface drying out. The orbicularis oculi muscle closes the lids and is powered by the facial nerve (cranial nerve VII). If the muscle is weak, the lids are tethered by scarring, or the eye bulges forward, the lids cannot cover the eye. The exposed cornea dries, becomes damaged (exposure keratopathy), and can ulcerate or become infected.

Causes

Facial nerve weakness (paralytic lagophthalmos)

• Bell's palsy: sudden one-sided facial weakness, the most common cause
• Stroke
• Tumors such as acoustic neuroma, and surgery near the facial nerve
• Ramsay Hunt syndrome (shingles of the facial nerve)
• Trauma, Lyme disease, Guillain-Barré syndrome and other facial nerve palsies

Eyelid problems (cicatricial lagophthalmos)

• Scarring from burns, injuries or skin disease
• Overly aggressive eyelid surgery (blepharoplasty) or ptosis repair
• Eyelid tumors

Bulging eyes (proptosis)

• Thyroid eye disease, in which tissues behind the eye swell and push it forward
• Orbital tumors or inflammation

Nocturnal lagophthalmos

Some people sleep with their eyes slightly open without any nerve problem. It is common, often runs in families, and may be associated with prominent eyes or lid laxity. It frequently goes unnoticed until it causes morning dry eye symptoms.

Other causes

• Reduced alertness or sedation in intensive care
• Neurological conditions that reduce blinking, such as Parkinson's disease

Symptoms

• Dry, gritty or burning eyes, often worst on waking
• A sensation of something in the eye
• Red eyes
• Watery eyes, as the eye reflexively tries to compensate
• Blurred or fluctuating vision
• Light sensitivity
• Pain, if the cornea is damaged
• A visible gap between the lids when trying to close the eyes

Diagnosis

An eye doctor will:

• watch you close your eyes gently and forcefully, and measure any gap
• check the blink reflex and the Bell's phenomenon (the eye's natural upward roll during closure, which offers some protection)
• examine the cornea with fluorescein dye under a slit lamp to look for dry patches, abrasions or ulcers
• check facial nerve function and eye position
• ask a partner whether your eyes stay open during sleep

Further tests, such as MRI or thyroid blood tests, depend on the suspected cause.

Treatment

Protecting the eye

• Lubricating eye drops during the day, preservative-free if used often
• Lubricating ointment or gel at night
• Taping the eyelids closed at night with medical tape, or using a moisture chamber or sleep goggles
• Humidifier and avoiding fans blowing on the face
• Punctal plugs to keep tears on the eye longer

Treating the cause

• Bell's palsy: steroids, ideally within 72 hours, with or without antivirals. Most people recover within weeks to months, and eye protection is needed until the lid closes fully
• Thyroid eye disease: specialist treatment of inflammation, and orbital surgery in selected cases

Procedures and surgery

• Eyelid weight implants: a small gold or platinum weight placed in the upper lid helps it close by gravity
• Botulinum toxin injection to temporarily lower the upper lid
• Tarsorrhaphy: partially sewing the lids together to protect the eye, temporary or permanent
• Eyelid tightening or lifting procedures and skin grafts for scarring
• Facial nerve repair or reanimation surgery in selected cases

Complications

• Exposure keratopathy and chronic dry eye
• Corneal abrasion
• Corneal ulcer and infection
• Corneal scarring and permanent vision loss in severe cases

Frequently asked questions

What is lagophthalmos?

Lagophthalmos is the inability to close the eyelids completely. It leaves part of the eye exposed, causing dryness, irritation and, if untreated, damage to the cornea. It can occur during sleep only or all the time.

What causes lagophthalmos?

Common causes include facial nerve weakness from Bell's palsy, stroke or surgery, eyelid scarring after injury or cosmetic surgery, and bulging eyes from thyroid eye disease. Some people simply sleep with their eyes slightly open.

Is it harmful to sleep with your eyes open?

It can be. Nocturnal lagophthalmos dries the eye overnight, causing morning irritation and, over time, damage to the cornea. Lubricating ointment at night and taping or sleep goggles usually protect the eye effectively.

How is lagophthalmos treated?

Treatment includes lubricating drops and ointment, taping the eyes closed or using moisture goggles at night, and treating the cause. Severe or permanent cases may need an eyelid weight, botulinum toxin, tarsorrhaphy or other eyelid surgery.

Does lagophthalmos go away?

It depends on the cause. Lagophthalmos from Bell's palsy usually improves as facial strength returns over weeks to months. Lagophthalmos from scarring or permanent nerve damage may need ongoing eye protection or surgery.