Lagophthalmos: Causes, symptoms and treatment

Our eyes are not only our organs of sight, but also one of the most striking features of our face. Therefore, eye health is of great importance in terms of both visual function and quality of life. However, disorders that significantly affect eye health can occur. Among these disorders, lagophthalmos is one of the most common. This condition prevents the eyes from closing completely and healthily. If you would like to learn more about this condition, please take a look at our content. We wish you all healthy days and happy reading.

What is Lagophthalmos?

Lagophthalmos is a condition in which the eyelids cannot close completely, usually caused by weakness of the muscles that close the eyelids, damage to the facial nerve (e.g., Bell's palsy or post-traumatic), or congenital or acquired deformities in the structure of the eyelids. As a result of this condition, the eyelids cannot close completely and the surface of the eye is left inadequately protected. If this condition is not treated adequately, the surface of the eye (cornea) remains exposed for long periods of time, which can lead to serious complications such as scratches, infections, or ulcers. Therefore, it is important to recognize the symptoms early and consult an eye specialist.

Types of Lagophthalmos

There are three different types of lagophthalmos. These types are classified according to their causes and the degree of dysfunction in the eyelid. To discuss these types in more detail, they are as follows:

Nocturnal Lagophthalmos

Nocturnal lagoftalmia is a condition in which a person is unable to completely close their eyelids while sleeping. This condition may not be noticeable during the day, but because the surface of the eye remains exposed throughout the night, it manifests itself in the morning with complaints such as noticeable dryness, stinging, burning, redness, and watering. Due to the prolonged exposure of the eye surface, the corneal layer may become dry, scratched, and sensitive. Furthermore, nocturnal lagophthalmos is often associated with eyelid laxity, anatomical differences, decreased facial muscle tone during sleep, or mild neurological dysfunction. Therefore, treatment typically involves protecting the eye surface using thick artificial tear gels, moisturizing ointments, special moisturizing goggles, or mild eyelid taping at night.

Paralytic Lagophthalmos

Paralytic lagophthalmos develops as a result of impaired neurological control of the orbicularis oculi muscle, which closes the eyelid. This condition usually occurs due to facial nerve palsy (Bell's palsy), trauma to the facial nerve, infection, tumor, or damage after brain surgery, and because the nerve is not working, the eyelids cannot close effectively and the surface of the eye remains constantly exposed. In this context, paralytic lagophthalmos causes the cornea to dry out, constant tearing, a feeling of foreign body, and an increased risk of infection. Therefore, treatment is planned according to the potential for nerve function recovery; intensive moisturization, eyelid bandaging, or moisture-focused protection may be applied in the short term, while in permanent cases, gold or platinum eyelid weights, lateral eyelid tightening, or other reconstructive surgeries may be preferred.

Mechanical Lagophthalmos

Mechanical lagophthalmos refers to conditions in which a physical barrier makes it difficult or impossible for the eyelid to close. This condition occurs due to post-traumatic contractures in the palpebral fissure, burns or surgical scars, tumors, mass formations, lid deformities, or uneven contractures between the eyebrow and the lid. Therefore, the mechanical movement of the lid is restricted, and the upper lid in particular cannot close completely during closure. For this reason, in treatment, the cause of the mechanical obstruction is first determined; if there is a mass, it is removed; if there is a lid deformity, reconstructive surgery is performed; if there is scar tissue, loosening procedures are applied. Additionally, moisturizing and eye surface protection treatments are administered simultaneously to control symptoms.

What Causes Lagophthalmos?

There are certain main symptoms of lagophthalmos. These symptoms vary from person to person, and each symptom may not manifest with the same intensity in every individual. In this context, the symptoms and signs of lagophthalmos are as follows:

• Incomplete closure of the eyelids (especially noticeable during sleep)
• Dryness in the eyes
• Burning, stinging, and itching
• Redness and irritation in the eyes
• Blurred vision, especially in the morning
• Excessive tearing (reflex lacrimation) – the drier the eyes, the more they water
• Sensitivity to light (photophobia)
• Foreign body sensation (gritty or stinging feeling)
• Scratches or damage to the corneal surface
• Eyes opening during sleep at night
• Frequent infections or development of keratitis

What Causes Lagophthalmos?

There are four main causes of lagophthalmos. These causes are: Lagophthalmos Due to Nerve Damage

Lagophthalmos Due to Eyelid Damage, Lagophthalmos Due to Moebius Syndrome, and Lagophthalmos Due to Bell's Palsy. Examining these causes in detail;

Lagophthalmos Due to Nerve Damage

Lagophthalmos due to nerve damage occurs as a result of loss of function of the facial nerve (7th cranial nerve). This condition arises from damage caused by trauma, infection, tumor, surgical intervention, or neurological diseases, leading to weakened muscle function and an inability to fully close the eyelids. It can also cause dryness, redness, burning, light sensitivity, and corneal injuries by causing the eye surface to remain constantly exposed. Treatment of the disease varies depending on the potential for reversal of nerve damage; intensive moisturizing and eyelid protection methods are used in temporary cases, while eyelid weights or eyelid tightening surgery may be necessary in cases of permanent damage.

Lagophthalmos Due to Eyelid Damage

Lagophthalmos associated with eyelid damage develops as a result of physical impairments such as trauma, burns, postoperative deformities, scarring, or retraction of the eyelid tissue restricting the movement of the eyelid, which can cause the eyelid to lose its natural position and result in incomplete closure. This condition leads to insufficient protection of the eye, dryness, foreign body sensation, and corneal irritation. At the same time, the larger the mechanical obstruction, the more pronounced the lagophthalmos becomes. Consequently, surgical methods such as releasing scar tissue, eyelid reconstruction, or grafting are used in treatment. As supportive treatment, the eye surface is protected with artificial tears and night ointments.

Lagophthalmos Due to Bell's Palsy

Moebius syndrome-related lagophthalmos occurs due to structural abnormalities affecting the facial nerves in Moebius syndrome, a congenital neurological syndrome. In this syndrome, the facial nerve (7th nerve) and abducens nerve (6th nerve) are often underdeveloped. Accordingly, congenital lagophthalmos is usually evident from childhood, and because the eye surface is left unprotected, there is an increased risk of dry eye, irritation, and corneal damage. Treatment usually involves long-term moisturization, protection with special glasses, nighttime eyelid taping, and, if necessary, surgical interventions to increase eyelid closure. Therefore, since Möbius syndrome is a permanent condition, the treatment strategy usually involves lifelong support.

Lagophthalmos Due to Moebius Syndrome

Bell's palsy-related lagophthalmos occurs as a result of sudden and usually temporary paralysis of the facial nerve, leading to impaired eyelid closure function. This type of disease can develop due to viral nerve inflammation or immune system reactions and is one of the most common causes of neurogenic lagophthalmos. As a result of the disease, the eyelids cannot close, causing the eye surface to rapidly lose its protective tear film, and the patient may experience symptoms such as dryness, watering, burning, and sensitivity to light. In this context, Bell's palsy can resolve within a few weeks to months in most cases, but protecting the eye during this process is very important. Therefore, artificial tears, gels and ointments, nighttime eyelid taping, and moisturizing goggles are used in treatment. If long-term recovery is delayed or the closing function does not return, eyelid weight surgery may be performed.

How is Lagophthalmos Diagnosed?

The diagnosis of lagophthalmos is made by an ophthalmologist through a clinical examination, which usually begins with a careful assessment of the patient's eyelid closure function. During this initial examination, the doctor checks how well the eyelids can close voluntarily and reflexively, whether there is any gap left during closure, and the strength of the blink. In addition, the amount of tear fluid, the moisture level of the eye surface, and signs of dryness or irritation of the cornea are examined in detail using a biomicroscope (slit lamp). During the examination, a fluorescein staining test may be performed; this test reveals dry or scratched areas on the eye surface. At the same time, the physician tests facial nerve functions to understand the underlying cause of lagophthalmos and may resort to neurological evaluation or imaging methods if necessary. Thus, if there is suspicion of deformity in the eyelid tissue, the eyelid structures are examined in detail. As a result, the type, severity, and possible causes of lagophthalmos are determined based on all these evaluations, and an appropriate treatment plan is developed.

How is Lagophthalmos Treated?

There are different treatment methods depending on the progression of lagophthalmos. These treatment methods are divided into two categories. The first is non-surgical treatment methods, and the other is surgical treatment methods. In this context, if we consider each separately;

Nonsurgical Treatments for Lagophthalmos

Non-surgical treatment of lagophthalmos is generally used as a first-line treatment in temporary situations where nerve recovery is expected or in mild cases of lagophthalmos. In this context, the main goal of treatment is to prevent the cornea from being exposed due to the inability of the eyelids to close completely and to reduce complaints such as dryness, irritation, and burning. The aforementioned non-surgical treatments for lagophthalmos are as follows:

• Artificial tear drops: Moisturize the eye surface throughout the day, reducing dryness and irritation.
• Eye gels and ointments: Used especially at night, they provide long-lasting moisturization.
• Eyelid taping: Prevents the eyes from opening during sleep, preventing the cornea from being exposed.
• Moisture goggles or night mask: Reduces evaporation by creating a moist environment around the eyes.
• Tear plugs: Alleviate dryness complaints by allowing tears to remain in the eye longer.
• Humidifying the environment: Using a humidifier at home or at work reduces eye dryness.
• Blinking exercises: Can help strengthen eyelid function and is particularly beneficial in mild cases.
• Avoiding wind, air conditioning, and prolonged screen time: Helps reduce eye dryness.

Surgical Treatments for Lagophthalmos

Surgical treatment for lagophthalmos is a surgical procedure primarily used in moderate to severe cases. This procedure aims to permanently improve the eyelid's closing function, protect the eye surface, and rearrange the eyelid anatomy. The procedures mentioned are as follows:

• Golden Eyelid Weight:

The golden eyelid weight procedure is one of the most common and effective methods used in the treatment of lagophthalmos. It is particularly preferred in cases of lagophthalmos caused by facial nerve palsy. This procedure helps the eyelid close, protecting the cornea and reducing the risk of dry eye and irritation. As a result, the golden eyelid weight procedure is reversible, and the weight can be changed or removed if necessary.

• Canthoplasty:

Canthoplasty is a surgical procedure aimed at strengthening the outer corner of the eyelid (lateral canthus). This procedure is particularly performed in patients with lower eyelid laxity or drooping at the edge of the eyelid. It increases the stability of the eyelid, supporting closure and ensuring better protection of the eye surface. Additionally, canthoplasty is often combined with other methods, such as gold eyelid weights.

• Eyelid Retraction Surgery:

This surgical method is used when the eyelid is positioned higher or lower than normal. In this context, eyelid retraction surgery improves the closing function by bringing the eyelid into the appropriate anatomical position. Thus, it provides flawless results in cases of thyroid eye disease or cases that develop after surgery.

• Eyelid Reconstruction Surgery:

Eyelid reconstruction surgery, performed in cases of tissue loss following trauma, tumor surgery, or previous surgeries, is a comprehensive treatment method. This method restores both functional closure and aesthetic integrity by reconstructing the eyelid. It also requires individualized planning and is generally preferred in advanced cases.

Things to Consider Before and After Lagophthalmos Surgery

There are certain key points to consider before and after lagophthalmos surgery. By paying attention to these points, you can ensure that both the preoperative and postoperative periods go smoothly. In this regard, the points to consider before and after lagophthalmos surgery are as follows:

Things to Consider Before Lagophthalmos Surgery

• A detailed eye examination should be performed. This allows for the assessment of lid aperture, dry eye, and tear quality.
• Neurological diseases and facial nerve functions must be reviewed.
• The medications used should be reported to the physician. In particular, blood thinners may be discontinued before surgery on the doctor's recommendation.
• Eye hygiene should be maintained, no makeup should be applied before surgery, and the eye area should be kept clean.
• Antibiotic or antiseptic eye drops recommended by the doctor should be used regularly before surgery.
• Realistic expectations should be established. In addition, the benefits and limitations of the surgery should be discussed openly with the doctor.
• If you smoke, reducing or quitting smoking will have a positive effect on the healing process.

Things to Consider After Lagophthalmos Surgery

• Cold compresses should be applied in the first few days. This reduces swelling and bruising.
• Artificial tear drops and protective ointments used at night should be used regularly.
• The eyelid should not be pressed, scratched, or rubbed.
• Makeup should not be applied around the eyes until the stitches are removed.
• Avoid lying face down. Instead, it is recommended to lie on your back with a slightly elevated pillow.
• Heavy sports, swimming pools, saunas, and bathhouses should be avoided for the period specified by the doctor.
• The surgical area should be kept clean; the dressing and care steps recommended by the doctor should not be neglected.
• The doctor should be notified immediately in case of unexpected pain, redness, discharge, or increased dryness.

If you suffer from lagophthalmos, you can contact Dr. Berke Özücer and his team, who deliver successful results in eyelid aesthetics.