Lagophthalmos: Symptoms, Types, Causes and Treatment

Lagophthalmos is a condition that may be unfamiliar to many, yet its consequences for eye health and quality of life are significant. Characterized by the inability to fully close the eyelids, lagophthalmos can lead to discomfort, vision problems, and even long-term ocular damage if left untreated. In this article, we will explore the key symptoms, types, causes, and modern approaches to treating lagophthalmos, drawing upon the latest clinical research and innovations in eye care.

Symptoms of Lagophthalmos

Lagophthalmos manifests in ways that can range from subtle to severe, often impacting daily comfort and eye health. Recognizing the symptoms early is crucial for preventing complications such as exposure keratopathy and corneal ulcers.

Symptom	Description	Severity	Source(s)
Incomplete Closure	Eyelids fail to meet fully, especially during blinking or sleep	Mild to Severe	1, 3, 4
Eye Dryness	Excessive evaporation of tears, causing discomfort	Moderate	1, 3
Redness & Irritation	Due to exposure and insufficient lubrication	Moderate to Severe	3, 4
Exposure Keratopathy	Corneal damage from chronic exposure	Severe	1, 3, 4, 6
Blurred Vision	Vision disturbance due to corneal involvement	Variable	3, 4
Poor Sleep Quality	Discomfort at night, possibly leading to sleep disruption	Mild to Moderate	1

Table 1: Key Symptoms

Recognizing the Signs

Symptoms of lagophthalmos often develop subtly. Patients may initially notice mild eye dryness or irritation, particularly upon waking in the morning. As the condition progresses, the inability to close the eyelids fully—either during blinking or sleep—becomes more apparent. Some individuals may be unaware of their eyelids failing to close at night (nocturnal lagophthalmos) until corneal symptoms develop 1 4.

Ocular Surface Complications

Chronic exposure of the cornea can result in:

• Redness and irritation
• Foreign body sensation
• Sensitivity to light
• Increased risk of infections

If left untreated, exposure keratopathy may progress to corneal ulceration, scarring, and potentially permanent vision loss 3 6.

Impact on Daily Life

Beyond physical symptoms, lagophthalmos can lead to:

• Cosmetic concerns due to visible eyelid malposition
• Sleep disturbances, especially in nocturnal lagophthalmos 1
• Reduced quality of life owing to chronic discomfort

Types of Lagophthalmos

Lagophthalmos is not a one-size-fits-all condition. It presents in several distinct forms, each with unique underlying mechanisms and treatment considerations.

Type	Defining Feature	Typical Cause	Source(s)
Paralytic	Incomplete closure from nerve dysfunction	Facial nerve palsy	2, 3, 5, 6, 7, 8, 9
Cicatricial	Eyelid scarring or structural change	Trauma, surgery, burns	3
Nocturnal	Incomplete closure during sleep	Congenital or hereditary	1, 4
Mechanical	Physical obstruction to closure	Proptosis, tumors	1
Obscure	Subtle, not easily visible on exam	Mild eyelid malposition	1

Table 2: Types of Lagophthalmos

Paralytic Lagophthalmos

This is the most common type and results from facial nerve dysfunction—most often Bell’s palsy, but also secondary to trauma, infections, tumors, or surgical nerve sacrifice 3 5 6 7 8 9. The orbicularis oculi muscle, responsible for closing the eyelid, becomes weak or paralyzed.

Cicatricial Lagophthalmos

Cicatricial lagophthalmos is due to eyelid scarring or contraction, commonly following trauma, burns, or surgical interventions that distort eyelid anatomy 3. Scar tissue restricts the normal movement and closure of the eyelid.

Nocturnal Lagophthalmos

Nocturnal lagophthalmos is characterized by the inability to close the eyelids during sleep. Unlike paralytic forms, patients may have normal voluntary eyelid movement when awake 1 4. This type may be hereditary and is often underrecognized because symptoms only manifest at night.

Mechanical & Obscure Lagophthalmos

Mechanical lagophthalmos occurs when a physical barrier—such as proptosis (bulging of the eye) or tumors—prevents eyelid closure 1. Obscure lagophthalmos refers to subtle cases where partial closure is not easily observed, often masked by eyelash obstruction or lid overhang 1.

Causes of Lagophthalmos

Understanding the root causes of lagophthalmos is key to effective management. Causes can be broadly categorized based on whether they affect the eyelid muscles, the supporting structures, or are due to external factors.

Cause Category	Specific Example(s)	Mechanism	Source(s)
Nerve Dysfunction	Bell’s palsy, facial nerve trauma	Paralysis of orbicularis oculi	2, 3, 5, 6, 7, 8, 9
Muscle Abnormality	Levator palpebrae thixotropy	Stiffness prevents closure	2, 5
Scarring	Post-surgical, burns, trauma	Cicatricial contracture	3
Anatomical	Proptosis, tumors, eyelid malposition	Mechanical obstruction	1
Hereditary	Congenital nocturnal lagophthalmos	Genetic factors	4

Table 3: Causes of Lagophthalmos

Facial Nerve Paralysis

The most common cause is facial nerve paralysis, particularly involving the seventh cranial nerve. This impairs the orbicularis oculi muscle, crucial for eyelid closure. Bell’s palsy is the leading culprit, but trauma, infections, tumors, or surgical removal of tumors (especially acoustic neuromas or parotid gland tumors) can also be responsible 3 5 6 8 9.

Muscle Stiffness: Thixotropy

Recent research highlights the role of levator palpebrae superioris muscle thixotropy—where the muscle fibers become stiff due to persistent actin-myosin crossbridges after peripheral facial nerve palsy. This means that lagophthalmos, in some cases, results from muscle stiffness, not just weakness of the closing muscles 2 5. Manipulating the eyelid to stretch the muscle can temporarily improve closure, suggesting a mechanical component.

Eyelid Scarring and Structural Changes

Cicatricial lagophthalmos arises when eyelid tissue is scarred, contracted, or distorted, as may occur after injury, burns, or reconstructive surgery 3. These changes physically prevent the eyelids from coming together.

Anatomical and Mechanical Causes

Proptosis (bulging of the eye due to thyroid eye disease or tumors), benign or malignant masses, and other anatomical abnormalities can prevent normal eyelid closure 1.

Congenital and Hereditary Factors

Some forms are congenital or hereditary, such as nocturnal lagophthalmos observed in families 4. In these cases, voluntary eyelid movement may be normal, but closure during sleep is impaired.

Treatment of Lagophthalmos

Effective treatment of lagophthalmos aims to protect the eye, restore eyelid function, and improve appearance. Management strategies are tailored to the underlying cause, severity, and patient needs.

Treatment Modality	Approach	Indication or Benefit	Source(s)
Lubricants	Eye drops/ointments	Mild to moderate cases, first-line	1, 3
Punctal Plugs	Block tear drainage	Severe dryness/exposure	1
Lid Loading	Gold/platinum weights	Paralytic lagophthalmos	6, 8
Injectable Fillers	Hyaluronic acid gel	Non-surgical/temporary solution	7
Static Surgery	Fascia/cartilage grafts	Severe, non-reversible cases	9
Dynamic Surgery	Reanimation of muscle	Selected cases, restore function	3
Minor Procedures	Tarsorrhaphy, chemodenervation	Temporary protection	1, 6

Table 4: Treatment Options

Lubrication and Conservative Management

For mild cases or as an initial step, frequent application of artificial tears and lubricating ointments protects the cornea from drying out. Punctal plugs can be used to reduce tear drainage and retain moisture 1 3.

Surgical and Procedural Interventions

Lid Loading (Eyelid Weights):
Implanting small gold or platinum weights into the upper eyelid allows gravity to assist in closure, especially for paralytic lagophthalmos. Platinum weights are now favored for their thinner profile and reduced complication rates compared to gold 6 8. This approach is simple, reversible, and effective, but may carry risks of extrusion, allergic reaction, or migration.

Injectable Fillers:
Hyaluronic acid gel injections into the upper eyelid offer a non-surgical, temporary alternative, especially valuable for patients who may recover nerve function or are poor surgical candidates. The filler is slowly resorbed and can be reversed if needed. Side effects are generally mild and transient 7.

Static Surgical Procedures:
For severe or long-standing cases, especially when recovery is unlikely, static procedures using the patient’s own tissues (such as fascia lata or cartilage grafts) can reconstruct and support the eyelid. These approaches avoid the risks of foreign material and have shown good outcomes in restoring closure and preventing keratitis 9.

Dynamic Surgical Techniques:
In select cases, dynamic reanimation of eyelid muscles may be attempted to restore natural movement, though this is more complex and reserved for specific situations 3.

Minor Procedures:
Temporary tarsorrhaphy (suturing part of the eyelids closed) or chemodenervation (inducing protective ptosis with botulinum toxin) may be employed as interim measures to protect the cornea, especially during the acute phase 1 6.

Individualized Treatment Planning

The choice of treatment depends on:

• The underlying cause and likelihood of recovery
• Severity and duration of lagophthalmos
• Patient age, health status, and expectations
• Cosmetic considerations

A multidisciplinary approach involving ophthalmologists, plastic surgeons, and sometimes neurologists is often required for optimal outcomes 1 3.

Conclusion

Lagophthalmos is a multifaceted condition with significant implications for ocular health and patient well-being. Early recognition and tailored management are essential to prevent vision-threatening complications and restore quality of life.

Key Takeaways:

• Lagophthalmos involves incomplete closure of the eyelids, leading to symptoms like dryness, irritation, and exposure keratopathy 1 3 4 6.
• Types include paralytic, cicatricial, nocturnal, mechanical, and obscure forms, each with distinct causes 1 3 4.
• Facial nerve paralysis (e.g., Bell’s palsy), muscle stiffness, scarring, anatomical, and hereditary factors are common causes 2 3 5 9.
• Treatment aims to protect the eye and restore eyelid function, with options ranging from lubricants and punctal plugs to eyelid weights, injectable fillers, and reconstructive surgery 1 3 6 7 8 9.
• Early diagnosis and individualized care are vital for optimal visual and cosmetic outcomes.

With advancements in both surgical and non-surgical options, most patients with lagophthalmos can achieve significant relief and preservation of vision when managed appropriately.