Nocturnal Lagophthalmos

By Eric Singman, M.D., Ph.D.
Subject Matter Expert, Neuro-Ophthalmology, Low Vision and Vision Rehabilitation
Vision Center of Excellence

Nocturnal Lagophthalmos (NL) is a condition in which the eyes do not completely shut when a patient falls asleep. Symptoms including a sense of dry eye upon awakening that can range from mild to quite severe. Patients can even experience spontaneous breakdown in the surface of the eye (the cornea), perceived as a significant foreign body sensation. Upon awakening the eye might also appear red, and there may be associated discharge or swelling. These symptoms might be present every morning or only a few mornings each month. Patients with NL have an elevated risk of suffering sleep apnea as well.

Risk factors for NL include the use of alcohol or sedatives prior to going to bed. Patients who are very nearsighted or who have cone-shaped corneas (keratoconus) are more often at risk. Patients who have suffered Bell’s palsy, stroke, or have conditions causing muscle weakness such as Myasthenia Gravis are also at elevated risk. Medical conditions that make the eyes protrude, such as Graves’ disease, or that cause scarring of the ocular surface such as might be seen in burn patients or patients suffering pemphigoid may develop lagophthalmos as well. Cosmetic surgery for droopy eyelids (a condition known as ptosis) and Botulinum Toxin injections for severe eyelid twitching (also called Blepharospasm) can also lead to NL.

Your eye doctor can often diagnosis NL based upon the history you provide and the appearance of damage to the surface of the eye, particularly the inferior cornea. In addition, your eye doctor might even ask you to relax in the exam room to see if your eyes close completely. Your might even be asked to request that your spouse quietly examine your eyes with a weak flashlight while you sleep to confirm whether NL is present.

The therapy for NL is directed at both the cause of the problem and the symptoms. In most cases, extra lubrication of the eyes before bedtime can be a great help. External eyelid weights (e.g., Med-Dev TM) which a patient can paste onto their own eyelids at night or even surgically implanted gold eyelid weights are available. Eye masks that provide gentle pressure (e.g., Tranquil-eyes TM) can help in milder cases, and even hypnosis has been reported to be useful. Novel surgeries that are available include the implantation of a spring into the eyelid (for severe cases) and cutting of a small muscle in the eyelid (Muellerectomy) for milder cases. It should be stressed that your eye doctor has a responsibility to help you and your family doctor explore the cause of the lagophthalmos; NL is a diagnosis made after other causes have been ruled out.

There is an entire branch of ophthalmology called oculoplastic surgery dedicated to the treatment of eyelid and facial skin disorders. The American Society of Ophthalmic and Plastic Reconstructive Surgery provides a website ( which should be an excellent starting point for patients with NL.