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Fellow eSTEEMed,

I had a friend in secondary school who never slept with his eyes closed. We thought he did it intentionally to give us the midnight horror when we wake up to ease ourselves. He later told us how he didn’t have control over it. All he knew was that he has been sleeping like that for a while. We joked about it, gossiped that he may be a witch and all other nonsense. Never knew he had the condition Nocturnal Lagophthalmos.

What is Nocturnal Lagophthalmos?

This is a condition when one is unable to close one’s eyes during sleep. Lagophthalmos itself is the inability to close one’s eyes completely. The origin of the word lagophthalmus comes from the Greek word “lagos” which means “Rabbit.” This is because rabbits are believed to sleep with their eyes open. According to Fuzzy-Rabbit, rabbits sleep often with their eyes open and it is mostly during the day. But one could know if they are asleep as they twitch and they don’t wiggle their nose.

According to Review of Optometry, the first individual to discuss on nocturnal lagophthalmos was Dr. Herbert Kaufman and along with Dr. Katz Jeffery described it as the exposure of the cornea during sleep which is a common cause of chronic keratitis which was previously undiagnosed.

What are the causes of Nocturnal Lagophthalmos?

The causes of nocturnal lagophthalmos can be divided into two which could be a damage/malfunction of the facial nerve (the seventh cranial nerve) or damage to the tissue of the eyelids.

Facial Nerve Malfunction/Damage

The facial nerve controls the actions of muscles that raise and close the eyelids. A malfunction or damage to this nerve will affect the closure of the eyelids and blinking of the lids. The following could cause the malfunction:

•Trauma/injury to the face can damage the nerve.

•Infections like mumps, chickenpox, leprosy, and Lyme disease can lead to the damage to the nerve.

•Bell’s palsy; this is when the facial nerve is inflamed or compressed causing the temporary paralysis of the muscles in the face. According to the American Academy of Ophthalmology, Bell’s palsy is associated with the herpes simplex virus.

•Möbius’ syndrome; this is a neurological disorder where the cranial nerve is paralyzed affecting eye movements. It is rare and congenital.

•Autoimmune conditions; this is when the defence of the body system, the immune system, attacks the components of the body. Eg. Guillain-Barre syndrome is when the immune system attacks the nerves of the peripheral nervous system.

•Tumors known as acoustic neuromas are noncancerous growth on the facial nerves causing partial paralysis of the muscles controlling the eyelids.

Eyelids Damage

The eyelids are made up of muscles and cells that ensure its perfect function. Damage to these tissues causes nocturnal lagophthalmos. The following could cause damage to the tissues:

•Burns or injuries to the eyelids tissues.
•Stevens-Johnson syndrome is a disorder of the skin that affects the eyes and mucous membranes. It is rare and classified as a type four hypersensitivity reaction.
•Floppy eyelid syndrome
•Eyelid surgery; e.g the removal of tumours or blepharoplasty. Blepharoplasty is the done to correct sagging eyelids. It could be for medical or cosmetic reasons. Damage to the eyelids can occur if too much skin is removed during the surgery. According to Eye Health Web, doctors believe there is an increased incidence of lagophthalmos because of the increasing number of blepharoplasty surgeries.

Symptoms of Nocturnal Lagophthalmos

Many with nocturnal lagophthalmos do not know they suffer from it unless someone sees them sleeping with their eyes open and tell them about it. But these additional symptoms will be helpful;

•Pain and irritation in the eyes early in the morning due to exposure of the eyes.

•Blurry vision and sensation of foreign bodies in the eyes leading to increased tears.

How is Nocturnal Lagophthalmos Diagnosed?

To diagnose nocturnal lagophthalmos, medical history is sought to determine cause of lagophthalmos. Trauma and surgery to the head are documented and past infections and diseased are reviewed, all these are done to determine the cause of the lagophthalmos.

In addition, physical examinations are done.
First to determine the space between the eyelids when it is closed (though it is not completely closed). The person is asked to look down and close both eyes. The doctor measures the space remaining between the lids with a ruler.

The blink rate is recorded and the blink is checked if it is complete.

The facial nerve function is tested by checking eye movements and strength of the facial muscles.

A slit lamp examination is done. It is also called a biomicroscopy.

Treatment for Nocturnal Lagophthalmos

The doctor determines the severity of the condition and determines the best method to treat lagophthalmos. There are surgical treatments and nonsurgical treatments.

Nonsurgical Treatment

•These are supportive methods. They take care of the lagophthalmos mostly. They include;
The use of artificial tears and ointment to prevent the eyes from itching and drying out.
The use of moisture-googles at night during sleep. It keeps the eyes moist and protects tears from evaporating.

•Temporary plugs made of collagen are used to block the tear duct. They are called punctual plug. They increase the amount of liquid in the eyes.

Surgical Treatment

There are various surgeries done depending on the patient’s choice and the severity. These include;

•Tarsorrhaphy; this is the sewing of the eyelids together leaving a small opening to see through. It could be temporary or permanent depending on the underlying cause of the lagophthalmos.

•Implantation of weights; gold weights are implanted on the upper eyelids or platinum weight is used if there is an allergy to gold. According to Eye health Web these weights are between 0.5 grams to 1.5 grams. They work by helping to completely close the eyes using gravity. But it can result in a blurred vision sometimes or have a side effect of inward turning of the eyelid called Entropion.

•Grafting can be used to elevating and tightening the lower eyelid, upper eyelid retraction, and for correcting facial nerve palsy.

Complications of Nocturnal Lagophthalmos

Managing lagophthalmos without treatment leaves the eyes dried making the eyes irritated and red most of the time due to injuries and scratches.

Continuous exposure of the eyes leads to exposure keratopathy. This is when the eyes are painful with a blurry vision which will eventually lead to chronic keratitis. This is the cornea getting inflamed and causing impaired eyesight.

Conclusion

Nocturnal lagophthalmos is not a curse or a superpower that makes your aware of your surroundings when you are asleep. It is curable and there is no need to shame someone with it. Advise anyone you know who has nocturnal lagophthalmos to visit a Opthamologist. It may May our eyes be closed when we want it and be protected.

Thank you for reading.

References

Lagophthalmos. Retrieved from Wikipedia

Lagophthalmos Evaluation and Treatment. Retrieved from American Academy of Ophthalmology

Lagophthalmos: Why Can’t I Close My Eyes? Retrieved from Healthline

Lagophthalmos — Why It Develops and How It’s Treated. Retrieved from Eye Health Web

'Like Sandpaper in the Morning'
Here’s how you can help break the vicious cycle of nocturnal lagophthalmos. Retrieved from Review of Optometry

Rabbit Behavior. Retrieved from Fuzzy-Rabbit

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