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.
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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.
Contact Lens Spectrum, Issue: December 2006