Open eyes -lagophthalmos

How to diagnose and treat lagophthalmos patients


Physicians should be more suspicious of lagophthalmos, the inability to fully close the eyelids, when patients present with redness, blurry vision, or eye irritation, especially if they are more frequent at night.
Although there are few literature reports on lagophthalmos, some practitioners think its prevalence is on the rise.
“Back in the 1960’s and 70’s, there were reports of a 4% (prevalence),” said Robert L. Latkany, M.D., assistant professor, New York Medical College, and founder and director, Center for Ocular Tear Film Disorders, White Plains, N.Y., who wrote a review paper this year on lagophthalmos published in The Ocular Surface. “I think the prevalence is more like 10% to 20%.”
Surgeries that might exacerbate existing lagophthalmos or even cause the problem itself are one reason the incidence of lagophthalmos has increased, Dr. Latkany believes. There are also more subtle variations of the problem that have led Dr. Latkany to cite an increased incidence.
Patients usually do not see their eye doctor for lagophthalmos-related symptoms such as morning irritation, foreign-body sensation, scratchy eyes and mucous discharge, said Christopher J. Rapuano, M.D., professor of ophthalmology, Jefferson Medical College of Thomas Jefferson University, and co-director, Cornea Service, Wills Eye Hospital, Philadelphia.
Here are some ways to distinguish between two types of lagophthalmos and treat its symptoms.

Diagnosis steps

Diagnosis of lagophthalmos depends on clinical examination, the type of lagophthalmos, and what is causing the lagophthalmos in the first place.
“Lagophthalmos is a sign due to many causes rather than a disease by itself,” said Chee Chew Yip, M.D., Alexandra Hospital, The Eye Institute, Singapore.
One kind of lagophthalmos is nocturnal, which occurs while the patient is sleeping. With the second kind of lagophthalmos, the patient cannot fully close their eyelids at any time.
Causes of lagophthalmos include facial nerve palsies, Bell’s palsy, thyroid disease, and Graves’ disease, Dr. Yip said. Sometimes it is hereditary. It could also be caused by a tumor (such as a cerebellopontine angle tumor), which is why diagnosis is so important, Dr. Yip said.
Eyelid surgery, also known as blepharoplasty, can exacerbate existing lagophthalmos or create new cases of it, Dr. Latkany said. Cases caused by blepharoplasty are seen more often now because the surgery is performed more frequently, he said.
The procedure can raise the eyelids too much or take too much skin off around the eyelid, Dr. Rapuano said. “Patients are often happy with how they look, but they can’t close their eyes all the way,” Dr. Rapuano said.
Although it can be hard to identify lagophthalmos, detection and treatment of it will help prevent problems if the patient is considering other surgical procedures such as LASIK, which may exacerbate dry eye associated with lagophthalmos.
“If a patient sleeps with their eyes open and everything is OK, that’s fine. However, if they’re going to have LASIK or they have conditions like diabetes, thyroid problems, or other issues that add to the dryness level, the combination of lagophthalmos and that condition will make the patient worse off,” Dr. Latkany said.
Nocturnal lagophthalmos can be hard to diagnose because the patients may not know if their eyes do not fully close at night unless someone has told them. It is also not a problem that practitioners often consider as a cause of dry eye-type symptoms, Dr. Rapuano said.
Nocturnal lagophthalmos patients may be poor sleepers and report slight or even strong pain in the morning, Dr. Latkany said. It can take their eyes five to 20 minutes before they feel normal upon awakening.
To examine whether patients can fully close their eyelids, Dr. Rapuano asks them in the examination room to close their eyes as if they are asleep. “You’ll see sometimes there is actually an opening of a couple millimeters. It’s that opening that’s the problem,” he said.
Dr. Latkany suggested waiting a few seconds before examining the patient’s eyes to avoid any voluntary closure. He will perform a slitlamp examination with a fine slit beam to limit additional voluntary closure.
Another option is to ask patients if someone can check their eyes in the middle of the night to see if the lids are completely closed, said Esen K. Akpek, M.D., associate professor of ophthalmology, The Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore.
Practitioners also can monitor blink frequency and quality when the patient is in the examination room. If a patient does not achieve full closure during each blink, most likely they do not fully close their eyelids at night, Dr. Latkany wrote in his review article.

Treatment options

Treatment options for lagophthamos patients range from dry-eye treatment to surgery: • Lubricants/gels: For mild lagophthalmos, the first treatment to try is the use of an ointment when the symptoms occur more frequently. For nocturnal lagophthalmos, patients can apply the ointment at night to protect the eye, Dr. Latkany said. However, “Some don’t like the way it feels or the blurriness upon waking,” he said. If lagophthalmos also occurs during the day, a lubricant that is not as thick as a nighttime ointment may be the answer, such as Refresh Celluvisc (Allergan, Irvine, Calif.) or GenTeal Gel (Novartis Ophthalmics, East Hanover, N.J.), Dr. Rapuano said.
• Taping of the lids: Taping the eyelids closed at night with the kind of tape used during surgery is another option, Dr. Akpek said. Patients even can use pieces of transparent tape they probably already have at home, she said. A weighted piece of tape such as that made by MedDev Corp. (Sunnyvale, Calif.) is another option, because it drops the eyelid to achieve full closure, Dr. Latkany said.
Dr. Rapuano thinks taping is a good short-term solution, but patients usually get skin redness and irritation if it is used for more than a couple of days.
• Treating the related dry eye: Some patients will feel relief from their irritation with a typical course of treatment for dry eyes. This can include artificial tears, Restasis (cyclosporine, Allergan) and punctal plugs, Dr. Latkany said.
• Nighttime moisture goggles: A product called tranquileyes (Eye Eco, Murrieta, Calif.), which Dr. Latkany described as “a fancy sleep mask,” can also provide more moisture to patients with nocturnal lagophthalmos. TranquilEyes are a soft, flexible goggle that create a moist environment around the eye and prevent evaporation of natural tears. Patients can wear the goggles while sleeping, relaxing, or in an environment where dry-eye symptoms are at their worst.
• Tarsorrhaphy: Surgical options, such as tarsorrhaphy, are yet another route for lagophthalmos patients, Dr. Latkany said. “Aside from an occasional unacceptable cosmetic result, [tarsorrhaphy] is usually quick and reversible and has few complications. Reducing the outer lid aperture yields a smaller exposed ocular surface area and facilitates management of ocular surface problems,” he wrote in his review article.
• Gold weight implantation: Other patients benefit from a gold weight placed in the upper eyelid by an oculoplastics specialist, Dr. Rapuano said. One problem with this option is the weights sometimes close one eye more than the other one, he said. Gold weight implantation is usually well tolerated, but it can produce blurry vision from corneal astigmatism and bulging of the implant, Dr. Latkany said.
• Prevention and surgery: A lagophthalmic patient who is considering refractive surgery, blepharoplasty, or Botox may benefit from seeing a corneal and external disease specialist first, Dr. Latkany said. Although it is not a given that patients will experience lagophthalmos after these procedures, the specialist can evaluate signs of a dysfunctional tear film that may be exacerbated, he said. Editors’ note: Dr. Akpek is on the speakers’ bureau for Allergan. Dr. Rapuano is a consultant for Alcon Laboratories (Fort Worth, Texas). Drs. Latkany and Yip have no financial interests related to their comments.