You might be sleeping with your eyelids partially open at night and not even know it! Sleeping with eyelids partially or fully open, aka Nocturnal lagophthalmos, is more common than you might think.
What is nocturnal lagophthalmos, and what can cause it?
Lagophthalmos is a condition characterized by the inability to fully close the eyelids (1) which can occur either during the day or night. Nocturnal lagophthalmos only occurs during sleep, but some patients can actually suffer from both types (2). This can be caused by medical conditions that cause the eye itself to protrude (Graves’ thyroid associated orbitopathy (TAO) or thyroid eye disease (TED), tumors, inflammation or other lesions behind the globe, etc) or by conditions which directly affect the functioning mechanisms of the eyelid (nerve damage, scarring, trauma or damage to the levator muscle, etc). There is also evidence that associates lagophthalmos with poor sleep and poor sleep quality (3,4). In either case, nocturnal lagophthalmos can lead to chronic dry eye, eye inflammation, increased risk of eye infections, and permanent corneal scarring which can impair vision.
Symptoms of nocturnal lagophthalmos
Since the cornea is exposed and dries out during sleep, normally patients will be most symptomatic in the morning upon awakening. Symptoms generally are blurred vision, discomfort, burning, watering, foreign body sensation, pain and redness. If the condition and associated corneal damage is mild, these symptoms generally improve throughout the day. Otherwise, they may persist throughout waking hours (or, can even worsen if there are other compounding causes of dry eye).
Treatment and management
Treatment of underlying cause: As mentioned previously, there are many causes for nocturnal lagophthalmos. Therefore, the most important treatment modality comes from investigating the primary cause of the condition. In cases of TAO/TED for example, working with your eyecare professional and endocrinologist (or other specialist) to adjust thyroid medication or make other recommendations is necessary. Some conditions affecting the cranial nerves controlling eyelid function can actually resolve on their own, so managing the night time exposure and dryness in the meantime may be all that is needed. For other neurological issues, they may not resolve fully (or at all), which could then warrant other therapies or surgery to aid in improvement of eyelid function or closure. Ask your eyecare professional for recommendations best-suited to your specific underlying cause.
Lubrication: Since nocturnal lagophthalmos only occurs during sleep, patients are generally advised to use a high viscosity lubricating gel or ointment in the eye before bed. Since these lubricants are thicker and more substantial than a typical artificial tear drop, they will generally blur your vision temporarily. If symptoms do not resolve during the day, use of a lower viscosity tear drop through the day may also be required (especially if both lagophthalmos and nocturnal lagophthalmos are present). If you are not sure what lubricants to use, or if a lubricant you are using is satisfactory - make sure to ask your optometrist.
Maintenance of moisture in the eyes overnight: After instilling lubricants, use moisture retaining goggles or eye masks like the Blinkjoy Hydrating Sleep Mask overnight to help to trap this humidity in and around the eye area during sleep.
Eyelid taping: Depending on the cause of the nocturnal lagophthalmos, gently taping the eyelids closed overnight can help to avoid exposure dryness (lubricate first, tape closed, moisture retaining eye mask over top). Ask your eyecare professional what types of tape are safe for use around the eyes.
Surgery: As mentioned, since there are so many causes for nocturnal lagophthalmos, the best surgical option depends entirely on the cause and whether the condition is potentially temporary or permanent. Tarsorrhaphy is one of the most frequently used surgical options especially in cases of Bells’ Palsy, where the seventh cranial nerve no longer functions optimally (or at all). A tarsorrhaphy partially stitches the eyelids together, reducing exposure. Newer studies are showing some evidence that photostimulation therapies like low level laser therapy (LLLT) can actually improve seventh nerve function in patients with Bells’ Palsy (Ref). Gold weight implantation into the upper eyelid can also help with eyelid closure. Most patients who have undergone eyelid surgery will normally still need to utilize the at-home remedy options, even post-operatively.
Environmental and lifestyle factors: Optimizing your sleep environment to inhibit or reduce other causes of dry eye can also be helpful. For example: using a humidifier, increasing water intake, supplementing omega-3, and making sure to take frequent breaks from screen use. Your optometrist can suggest more specifically which of the above could be most helpful in your case.
Routine eye care: Visiting your optometrist or eye care professional regularly is also an important step in monitoring of the condition and having management options adjusted as necessary.
Conclusion
As mentioned, there are several different treatment options for patients who suffer from nocturnal lagophthalmos. Many patients will require more than one of these management options to remain symptom-free. Always consult with a healthcare professional for the most personalized approach and to discuss the best options based on the severity of your condition.
References:
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Latkany, Robert, Barbara Lock, and Mark Speaker. "Nocturnal lagophthalmos: an overview and classification." The Ocular Surface 4.1 (2006): 44-53. https://www.sciencedirect.com/science/article/abs/pii/S154201241270263X
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Mastrota, Katherine M. "Diagnosing and treating lagophthalmos." Optometry Times 7.4 (2015): 12. https://www.optometrytimes.com/view/diagnosing-and-treating-lagophthalmos
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Tsai, Shawn H., et al. "Nocturnal lagophthalmos." International Journal of Gerontology 3.2 (2009): 89-95. https://www.sciencedirect.com/science/article/pii/S1873959809700274
- Takahashi, Aya, et al. "Nocturnal lagophthalmos and sleep quality in patients with dry eye disease." Life 10.7 (2020): 105. https://www.mdpi.com/2075-1729/10/7/105
Contributors:
Sarah Farrag, OD
Dr. Sarah Farrag is originally from Halifax, Nova Scotia, and is happy to be practicing optometry in her hometown. She graduated with honors from the University of Waterloo Doctor of Optometry program in June 2015. In addition to routine optometric care, Dr. Farrag also facilitates an advanced dry eye clinic offering specialty consultation and treatment for severe chronic dry eye.
