contact lens case reports
Nocturnal Lagophthalmos
BY PATRICK J. CAROLINE, FAAO, & MARK P. ANDRé, FAAO

Nocturnal lagophthalmos is the inability to maintain lid closure during sleep. The term lagophthalmos is derived from the Greek word lagos, meaning a hare, because the hare was believed to sleep with its eyes open. Nocturnal lagophthalmos is a surprisingly common condition with clinical manifestations that can range from a mild keratitis that may heal throughout the day to severe exposure ulcers.

There are a variety of predisposing factors associated with lagophthalmos including proptosis, or excessive ocular surface exposure secondary to facial palsy; lid deformity or trauma; palpebral insufficiency due to congenital or acquired conditions; or idiopathic as in the case of nocturnal lagophthalmos.

Signs and Symptoms

Nocturnal lagophthalmos most often presents as an area of epithelial punctate keratitis located in the inferior one-third to one-half of the cornea, sometimes combined with epithelial microcysts. The precise area of damage appears to be a function of exactly where the palpebral opening occurs in relation to the cornea. Some severe exposure may cause ulceration in the inferior portion of the cornea.

Subjective symptoms consist of soreness, dryness, foreign body sensation or sharp pain in one or both eyes, often associated with redness, watering and sometimes blurred vision.

The symptoms are most pronounced immediately upon awaking and tend to gradually improve throughout the day. If damage from exposure is severe, it may not heal during the waking hours.

Figure 1. The patient's left eye pre- and post-lid weight therapy.

Treatment

In mild cases, treatment consists of a thick ophthalmic ointment at night to provide protection to the cornea. If the condition is moderate to severe, taping the eyelid shut in conjunction with ointment is often successful. However, many patients object to nightly taping and worry about pulling out their eyelashes while removing the lid tape. Additionally, some patients may develop an allergic reaction to the adhesive.

Because idiopathic nocturnal lagophthalmos probably results from decreased lid muscle tonus at night, external eyelid weights may be a possible treatment modality.

Case Report

A 25-year-old female soft contact lens candidate presented with a long history of nocturnal lagophthalmos (worse in left eye) unresponsive to conventional therapies. We performed a trial with the Blinkeze External Lid Weights (MedDev Corp.). The diagnostic set consists of eight metallic tantalum weights from 0.6g to 1.8g in 0.2g increments. Practitioners can order the surface of the weights in a range of skin-tone colors to approximate a patient's complexion.

The weight is secured onto the pretarsal surface of the upper eyelid with a double-sided, hypoallergenic adhesive strip.

One week of therapy resulted in dramatic improvement in the patient's amount of staining and subjective symptoms (Figure 1). She also reported that the external lid weight was a more comfortable and acceptable modality than lid taping.

The authors wish to thank Shawn H. Tsai, MD, for his kind assistance with this manuscript.

Patrick Caroline is an associate professor of optometry at Pacific University and is an assistant professor of ophthalmology at the Oregon Health Sciences University. He is also a consultant to Paragon Vision Sciences and SynergEyes, Inc. Mark André is an associate professor of optometry at Pacific University. He is also a consultant for Alcon Labs, CooperVision and SynergEyes, Inc.