SLEEPING WITH EYES OPEN? EXPLORING NOCTURNAL LAGOPHTHALMOS

Medically Reviewed by Dr. Sony Sherpa (MBBS) - July 30, 2024

Did you ever wake up in the morning with dryness and irritation in one or both eyes? If so, you may have Nocturnal Lagophthalmos (NL), where a person sleeps with both eyes or one eye partially open.

The eyes need to remain closed during sleep and blink frequently during the day to get rid of dust and other matter. The eyes continuously secrete tears to protect the top layer and cleanse them. The tears also help the eyelids to move safely over the ocular surface.

When a person sleeps with their eyes open, the eyelids do not fully cover the cornea, exposing it to materials that can scratch the eye and cause potential damage. While asleep, a person does not blink, and the tears secreted by the open eyes evaporate. Excessive exposure to dust and other materials can lead to dryness, irritation, and even vision loss if left untreated.

Nocturnal lagophthalmos is one of several types of lagophthalmos, which is the inability to close the eyes. The reasons for lagophthalmos are similar across types and include nerve damage, infection, tumors, and other conditions that affect the function of the nerves and muscles of the eyelids.

NL has no known prevalence, yet experts suspect it occurs in roughly 5% of the general population and is an overlooked cause of dry, irritated eyes^[1]. Although it can happen to anyone, regardless of age or gender, significantly impacting eye health and sleep quality, it is more prevalent in older adults, with a higher incidence in those over 60.

This blog explores the causes, symptoms, potential complications, common myths, treatment, and management options for Nocturnal Lagophthalmos.

Causes of Nocturnal Lagophthalmos

There are several potential causes of lagophthalmos, including^[2]:

• Anatomical or Palpebral Insufficiency: Anatomical or palpebral insufficiency refers to the inability of the eyelids to close fully due to weak eyelid muscles or eyelid abnormalities. Certain medical conditions cause severe scarring of the eyelids that results in the same issues as sleeping with open eyes.
• Neurological Conditions: Certain neurological conditions, such as Bell’s Palsy or facial nerve damage, can affect the muscles responsible for closing the eyelids, leading to drooping eyelids and Nocturnal lagophthalmos.
• Proptosis: Proptosis, also known as exophthalmos, is a condition where the eyeball protrudes from the eye socket. Thyroid eye disease, tumors, trauma, or cosmetic eye surgery (blepharoplasty) can cause proptosis, leading to the inability to close the eyelids fully.^[3]
• Floppy Eyelid Syndrome. This condition happens when the eyelids are very loose and flexible. It causes them to sag and can make it difficult for them to move optimally. Floppy eyelid syndrome may be linked to obesity, sleep apnea, and connective tissue disorders.^[4]
• Lifestyle Factors: Certain lifestyle factors that increase nervous system toxicity, such as smoking or excessive alcohol consumption, can also contribute to Nocturnal lagophthalmos. Vitamin A deficiency and exposure to toxins like arsenic, carbon monoxide, or thalidomide may induce the condition, too.
• Aging: As we age, the muscles responsible for closing the eyelids can weaken, making it difficult to close the eyes fully during sleep. The eyes also produce fewer tears, making them more susceptible to damage and NL symptoms.

Nocturnal Lagophthalmos Symptoms

The most common symptom of Nocturnal lagophthalmos is waking up with dry, irritated eyes.

Other symptoms may include:^[5]

• Blurry vision upon waking up
• Eye redness
• Eye irritation or discomfort
• Sensitivity to light
• Difficulty fully closing the eyes
• Excessive tearing
• Eye discharge

People with NL also experience insomnia and a worsening of symptoms upon waking in the morning or in the middle of the night.

Studies suggest that those with severe NL related to dry eye disease experience a shorter sleep duration, lower sleep quality, and a longer time to transition from wakefulness to sleep.^[6]

Can NL Affect Only One Eye?

Yes, Nocturnal lagophthalmos can affect only one eye. This can occur for various reasons, such as facial nerve damage or eyelid abnormalities, which may only affect one eye.

Potential Long-Term Complications

If left untreated, Nocturnal Lagophthalmos may lead to long-term complications, including:

• Vision Loss: The cornea focuses light onto the retina, allowing us to see. When exposed to Nocturnal lagophthalmos, the cornea can lead to dryness, irritation, and even vision loss.
• Corneal Ulcers: Corneal ulcers are blisters or open sores on the eye’s cornea that can occur due to infection or injury. When exposed to Nocturnal lagophthalmos, the cornea is more susceptible to developing corneal ulcers.
• Eye Irritants: When the cornea is exposed, it is more vulnerable to eye irritants, such as dust, pollen, or other environmental factors.
• Dry Eye Disease: Nocturnal lagophthalmos can lead to dryness of the eyes, which can contribute to the development of dry eye disease.^[7]
• Sleep Disturbances: Sleeping with your eyes open can lead to poor sleep quality, significantly impacting overall health and well-being.

Common Myths About Nocturnal Lagophthalmos

Several myths about Nocturnal Lagophthalmos are not valid. Some common ones include:

Myth: NL only affects older adults

• Fact: While Nocturnal lagophthalmos is more prevalent in older individuals, it can occur in anyone at any age.

Myth: It affects both eyes in every case

• Fact: Nocturnal lagophthalmos can affect one or both eyes.

Myth: NL is not a severe condition

• Fact: Nocturnal lagophthalmos can lead to permanent eye damage and other potential complications if left untreated.

It is vital to seek out treatment if you suspect you may be experiencing Nocturnal lagophthalmos.

How Do I Prevent Sleeping With Open Eyes?

If you are at risk for Nocturnal lagophthalmos, taking steps to prevent the condition can help reduce the likelihood of developing it. Preventive measures include avoiding excessive alcohol consumption, quitting smoking, and practicing good sleep hygiene.

Diagnosis and Evaluation

If you suspect you may be experiencing Nocturnal lagophthalmos, it is essential to consult with an eye specialist for a proper diagnosis and evaluation.

Your ophthalmologist may carry out the below tests:

• Slit-Lamp Examinations: A slit-lamp examination is a non-invasive test that allows an eye specialist to examine the inner compartments of your eye, including the eyelids, cornea, and iris.
• Tear Production Tests: Your eye doctor may perform a tear production test to determine if you have dry eyes, which can contribute to Nocturnal lagophthalmos.
• Fluorescein Eye Stain Test: A fluorescein eye stain test involves placing a special dye in your eye to detect any damage to the cornea.

Nocturnal Lagophthalmos Management and Treatment Options

The treatment options for Nocturnal Lagophthalmos will depend on the underlying cause and severity of the condition.

Treatment first tackles underlying problems, such as nerve disorders, trauma, or infections. These may require specialist care from a neurologist, endocrinologist, or ophthalmologist.^[8]

Managing NL demands keeping the eyes moist to prevent or improve symptoms of dry eye. An eye doctor often recommends eye drops or gels to reduce dryness and irritation.

Keeping the eyes closed at night is the next focus. Several strategies can accomplish this:^[9]

• Eyelid Muscle Exercises: In some cases, strengthening the muscles responsible for closing the eyelids can help improve the condition. Stimulating the eyelids with gentle eye rolls, practiced blinks, eyebrow raises, or light massage may help with eyelid strength and improve eye dryness. Holding the eyelid gently between two fingers while trying to close them can create resistance and build muscle.
• An Eye Patch: Those with trouble in one eye may benefit from wearing a patch over the good eye during the day. An eye patch can help the problem eye "workout" more, potentially strengthening the eyelid.
• Sleep Mask: Some people may avoid NL with a sleeping mask to keep their eyes closed, covered, and protected at night. Placing eye gels in the mask may help to keep them moist. However, the mask needs frequent cleaning to prevent residue buildup and infections.
• Surgical Tape: Using surgical tape to keep the eyelids closed while sleeping can help alleviate symptoms. In some cases, it may strengthen the eyelid muscles and help to retrain them to keep them closed at night.

These measures may facilitate recovery from NL while receiving treatment for any underlying condition, primarily if related to recovery from facial trauma, nerve damage, or an eye procedure.

If these measures fail to keep the eyes shut at night, you may resort to a more comprehensive treatment solution to minimize eye damage. Options can include:

• Gold Weights: Gold weights can be surgically implanted into the eyelids to help them close fully.^[10]
• Botox Injection: Botox injections can help relax the muscles responsible for keeping the eyes open, causing them to droop closed.^[11] These injections work best for patients without drooping eyelids who must keep their eyes closed for other reasons.
• Eyelid Tightening: In severe cases, surgery may be necessary to tighten the eyelids and improve their ability to close fully.^[12]
• Upper eyelid retraction. Upper eyelid retraction recession is effective for lagophthalmos in thyroid ophthalmopathy.
• Other Surgeries: Procedures like skin grafts, flaps, tarsal-sharing, and scar band release can help in lagophthalmos due to scarring or eye surgery complications.

Latest Technology and Advancements

Advancements in technology have led to new treatment options for Nocturnal lagophthalmos. One such advancement is using moisture goggles, which can help keep the eyes lubricated and protected while sleeping.

Conclusion

Nocturnal lagophthalmos is a relatively common condition that can significantly impact eye health and sleep quality. If you suspect you may be experiencing Nocturnal lagophthalmos, seeking treatment from an eye doctor is essential. With the proper treatment and management strategies, you can improve your eye health and sleep quality.

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