BASICS

DESCRIPTION

Corneal damage due to evaporative tear loss and disrupted tear dynamics in the setting of improper lid closure and movement.

EPIDEMIOLOGY

Incidence

Uncommon

Prevalence

Low overall, but prevalence increases with age.

GENERAL PREVENTION

Identification of at risk patients and prompt intervention to prevent serious corneal complications

PATHOPHYSIOLOGY

• The lack of normal movement of the eyelids (especially the upper lid) leads to loss of the normal protective tear film over the surface of the cornea.

• Without normal eyelid movements the tear film is disrupted for several reasons:

– Evaporation loss of tears exposed within the palpebral fissure

– Decreased spread of replenished tears across the cornea

– Abnormal mixing of tear layer components (mucin, lipid, and aqueous)

– Inadequate drainage of tears through the nasolacrimal system with loss of normal tear recycling

ETIOLOGY

• Neurogenic

– Facial nerve palsy (e.g., Bell’s palsy)

• Anatomic

– Cicatricial or restrictive diseases of the lids

– Prior blepharoplasty

– Skin/mucous membrane disorders (e.g., Stevens–Johnson Syndrome)

– Ocular proptosis (e.g., Orbital tumors, Graves’ disease)

• Degenerative

– For example, Parkinson’s, Alzheimer’s, dementia

• Altered mental state

COMMONLY ASSOCIATED CONDITIONS

• Bell’s palsy

• Parkinson’s disease

• Lower lid ectropion

• Corneal neurotrophism

DIAGNOSIS

HISTORY

• Typically can elicit a history of one of the etiologies listed above

• May elicit a history of lid opening at night (nocturnal lagophthalmos)

• Typically subacute or chronic in presentation

• Symptoms may include the following:

– Foreign body sensation

– Photophobia

– Tearing

– Decreased visual acuity

PHYSICAL EXAM

• External examination may demonstrate:

– Failure of lids to close fully on blink or voluntary closure (lagophthalmos)

– Decreased frequency of blink

– Widened palpebral fissure

– Ectropion or lid position abnormalities

– Brow ptosis (in cases of facial paralysis)

• Slit-lamp examination may demonstrate:

– Corneal punctate epithelial erosions (most dense inferiorly but may be diffuse if severe exposure or if markedly decreased blink frequency)

– Decreased tear break up time

– Decreased tear production (in cases of facial paralysis)

– Corneal ulceration, infection, thinning, scarring, or perforation if severe or prolonged

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic Procedures/Other

• Observe spontaneous blink rate and eyelid closure prior to placing anesthetic

– Ask patient to close eyes gently and measure palpebral fissure

– Ask patient to forcibly close eyes and measure palpebral fissure

• Check corneal sensation prior to placing anesthetic to rule out neurotrophic disease

• Stain corneal surface with fluorescein to help identify punctate erosions and measure tear break up time

• Consider measuring tear production with a Schirmer’s test

• Note: In office, testing of Bell’s phenomenon may be misleading as it does not often correlate well with corneal position during sleep or during involuntary lid closure.

DIFFERENTIAL DIAGNOSIS

• Dry eye syndrome

• Sjögren’s syndrome

• Neurotrophic keratopathy

• Medicamentosa

• Blepharitis

TREATMENT

MEDICATION

First Line

• Lubrication: Strategy and aggressiveness of lubrication varies with etiology (e.g., although nocturnal lagophthalmos may only require ointment at bed time, a Bell’s palsy patient with a wide palpebral fissure will require frequent instillation) (1)

– Artificial tear supplements (short-lived effect, use ≥4 times/day)

– Viscous gels (longer effect)

– Ointments (longest lasting effect)

• Eyelid taping/placement of cellophane dressing over eyelids during sleep, obtundation, or unconsciousness (e.g., general anesthesia)

Second Line

Surgical procedures to improve lid closure may be considered when lubrication and lid taping are either insufficient or intolerable, or if the condition becomes a chronic disability

ADDITIONAL TREATMENT

Issues for Referral

Lid procedures such as gold weight placement are typically performed by oculoplastics-trained ophthalmologists.

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