Eyeworld

EW NEWS & OPINION 28 April 2017 by Vanessa Caceres EyeWorld Contributing Writer needed to open eyelid closure by the patient can be assessed and may reveal a palsy," Dr. Howard said. Other patients may not have obvious signs of lagophthalmos until they are in a supine position, making it harder to diagnose. "At nighttime, when the patient is sleep- ing, they may have lagophthalmos that is not as evident on routine examination," Dr. Rand said. Clinicians should also test for corneal sensitivity when assessing lagophthalmos and dry eye as its presence could increase the risk of epithelial defects and corneal ulcers, Dr. Howard said. Treating lagophthalmos Treatment options for lagophthal- mos abound. For the most part, they are effective, according to physicians interviewed for this article. One common first-line treat- ment is the use of lubricating eye drops during the daytime and an ophthalmic lubricating gel at night. Punctal plugs are another con- sideration. "They can be placed to promote retention of natural tears and artificial lubricants on the eye surface, and dry eye vitamins may improve lubrication as well," Dr. Howard said. Moisture chamber goggles are helpful for some patients at night. Because of the poor sleep and discomfort associated with noctur- nal lagophthalmos, some patients require additional lubricant or even There are also patients who have lagophthalmos but are not aware of it. Dry eye, allergies, and blepha- ritis can be commonly seen in con- junction with lagophthalmos. If left untreated, the condi- tion can lead to other serious eye problems. First, the presence of a complete blink reflex protects the eyes, spreading the tears completely over the surface of the cornea, Dr. Nicola said. When this does not occur, insufficient lubrication of the cornea or conjunctiva can result in potential scarring with vision loss or increased infection risk, Dr. Howard said. Diagnosing lagophthalmos Ophthalmologists will consider sub- jective complaints such as tearing, eye redness, blurry vision that im- proves with blinking, and mild eye pain when diagnosing lagophthal- mos. "On exam, I will notice inferior conjunctival and corneal staining and injection…These patients often complain of glare and photophobia also," Dr. Nicola said. "I will usually ask the patient to relax with their eyes closed at the slit lamp," Dr. Rand said. "There may be obvious lack of full eyelid closure, but a subset of patients will have initial eyelid closure, followed by a gap between upper and lower eyelid that may occur after a few moments of relaxation." "If weakness of the orbicularis oculi muscle is suspected, the force Howard, MD, Sharp Chula Vista Medical Center, San Diego, believes it to be present in 4% to 20% of the population. However, some research has tracked a 5% incidence of noc- turnal lagophthalmos and a 10% in- cidence of persistent lagophthalmos after ptosis surgery, she said. In addition to its occurrence after blepharoplasty, other condi- tions with which lagophthalmos can occur include thyroid disease and exophthalmos, post-eyelid cancer removal, Bell's palsy, and stroke, said Mark Goldfarb, MD, Advanced Eyecare, River Edge, New Jersey Lagophthalmos usually falls into two categories—congenital and acquired, Dr. Howard said. "That associated with palpebral insuffi- ciency also can be categorized into congenital and acquired, with the acquired form resulting most often from Bell's palsy, post-surgical or post-trauma, scarring disorders such as ocular cicatricial pemphigoid, and involutional ectropion," she said. At night, lagophthalmos can oc- cur or be worsened in patients using a continuous positive airway pres- sure (CPAP) mask for sleep apnea, as the oxygen often blows across the exposed corneas if a poorly fitted mask is used, Dr. Nicola said. Dr. Goldfarb has coined the term computer lagophthalmos for patients whose blink rate slows down as they are using the comput- er. Often, these patients experience dry eye and concurrent lagophthal- mos. This form of the condition is underrecognized, Dr. Goldfarb believes. Condition may be on the rise, is associated with various causes, and has several possible treatments L agophthalmos, the in- ability to close the eyelids completely, is a condition that can arise with many different ocular surface and health issues. Some ophthalmol- ogists report a higher incidence of lagophthalmos due to an aging population and an increase in plastic surgery procedures such as blepha- roplasty, said Allison L. Rand, MD, Rand Eye Institute, Deerfield Beach, Florida In fact, 62% of facial plastic surgeons report a rise in eyelid procedures, according to a survey released in January by the American Academy of Facial Plastic and Recon- structive Surgery. "As a corneal specialist in a high-volume practice, I see lagoph- thalmos from mild to severe, asso- ciated with various causes, several times a day," Dr. Rand said. Paula Nicola, MD, EyeCare Chattanooga, Chattanooga, Ten- nessee, believes that she works with lagophthalmos patients more than other ophthalmologists because she is at a tertiary referral center and will see patients following trauma, including facial fractures or chemi- cal burns. Although there are few formal studies regarding the incidence of la- gophthalmos among patients, Gayle A closer look at lagophthalmos continued on page 30 This is the right eye of a woman in her 50s who had blepharoplasty many years ago. She doesn't have much eye pain, but has developed significant inferior corneal scarring over a long period of time due to non-compliance with topical lubrication. Source (all): Allison Rand, MD

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