Sleeping With Your Eyes Open: Understanding Nocturnal Lagophthalmos
Closing your eyes is typically a defining feature of sleep, so it can be surprising to learn that some people sleep with their eyes partially or fully open. This condition, known as nocturnal lagophthalmos, is relatively common, affecting an estimated 1 in 20 people. While it might seem like a minor issue, sleeping with your eyes open can lead to discomfort, sleep disturbances, and potential eye health complications.
The Role of Eyelids in Sleep
Our eyelids play a crucial role in ensuring a good night’s sleep and maintaining eye health. They act as a protective barrier, shielding the eyes from debris and potential injury. Eyelids also provide lubrication, preventing the eyes from drying out and maintaining the integrity of the cornea.
Closing our eyes also blocks light, which is essential for calibrating the body’s internal 24-hour clock, also known as the circadian rhythm. Specific cells in the retina process light and send information to the hypothalamus, signaling that it’s time to be awake. When we experience darkness, melatonin is produced, telling our body it’s time to sleep. Therefore, keeping the eyes closed is essential for maintaining a healthy sleep-wake cycle.
What is Nocturnal Lagophthalmos?
Nocturnal lagophthalmos, sometimes referred to as nighttime lagophthalmos, is a condition where the eyelids do not fully close during sleep. In some cases, this may leave the eyes completely open. Other people may sleep with their eyes half open or just slightly open.
Lagophthalmos (la-guhp-THAL-mowz) is the general medical term for when the eyelids do not close completely. If this happens while you’re awake, it can be easier to diagnose than the nocturnal variant. This is especially so if your eyelids close normally during the day but not when you’re sleeping.
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Estimates of sleeping with the eyes open vary significantly. 5% of adults and up to 20% of the overall population are reported to experience nocturnal lagophthalmos. These estimates also vary according to ethnicity. Statistics specifically for children have not been reported. However, some babies do sleep with their eyes partially open. Cases of children sleeping with their eyes half open when they're sick have been reported, but this finding is uncommon. Because of the nature of nocturnal lagophthalmos, it is very likely underdiagnosed.
Causes of Nocturnal Lagophthalmos
Nocturnal lagophthalmos can have many causes, including faulty eyelid mechanics, facial nerve disorders, and structural changes in the face. Numerous conditions can predispose individuals to these issues:
Problems With Facial Nerves and Muscles: Issues with facial nerves and muscles surrounding the eyelid can cause the lid to remain open during sleep. Weakness in facial nerves can be attributed to several factors, including:
- Injury or trauma
- Stroke
- Tumor
- Bell’s palsy, a condition that causes temporary paralysis or weakness of facial muscles.
- Autoimmune disorders and infections, such as Lyme disease, chickenpox, Guillain-Barre syndrome, mumps, and several others.
- Moebius syndrome, a rare condition that causes problems with cranial nerves.
Proptosis (Bulging Eyeball): When the eyeball protrudes, it creates more surface area for the eyelids to cover. Possible causes of proptosis include thyroid disorders like Graves disease, congenital conditions affecting the anatomy of the face, an infection, or a tumor. A common symptom of Grave’s disease, a form of hypothyroidism, is protruding eyes. The bulging eyes, known as Graves’ ophthalmopathy, can prevent the eyes from closing.
Short or Weak Eyelids: Numerous conditions can either shorten the eyelids or decrease their muscle tone, thereby preventing the eyelids from fully closing. Medical procedures like eyelid-tightening surgery, Botox injection, and fat removal around the eyes can compromise eyelid height and tone.
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Damaged Eyelids: Eyelids can become damaged as a result of surgery, injury or illness, making it difficult to fully close the eyes during sleep. Furthermore, a condition known as floppy eyelid syndrome can also interfere with eye closure, and is often associated with obstructive sleep apnea (OSA). OSA is commonly linked to eye diseases like glaucoma and optic neuropathy.
Scarring: Physical trauma, chemical burn, and certain diseases such as ocular pemphigoid and Stevens-Johnson syndrome, can scar components of the eyelids and limit their function.
Nerve Problems: A range of problems affecting facial nerves can prevent the eyelids from functioning properly. These problems include Bell’s palsy, Lyme disease, and injuries.
Sedatives: Excessive alcohol and sedatives, including some sleeping pills, can sometimes cause nocturnal lagophthalmos.
Genetics: There also tends to be a genetic component to nocturnal lagophthalmos, as it often runs in families.
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Idiopathic: When there is no known cause for nocturnal lagophthalmos, it is classified as idiopathic.
In some circumstances, a person’s eyes can be open while they’re asleep without it meaning they have nocturnal lagophthalmos. For example, people who sleepwalk frequently have their eyes open during sleepwalking episodes.
Symptoms of Nocturnal Lagophthalmos
It can be hard to detect signs or symptoms of this condition since it occurs while you’re asleep. While your eyes may be open, the brain activity responsible for making sense of visual data is still temporarily off during sleep. As a result, it’s hard to know if this is happening unless someone observes you. Additionally, even though lids may appear to be closed during a doctor’s examination, this doesn’t mean they’re fully sealed. And if the lids aren’t properly sealed, it means they aren’t protecting the eyes from drying out overnight.
People who have nocturnal lagophthalmos may not even know they have it. It is difficult to evaluate whether your eyes are closed when you're actually asleep. Even if another person observes you while you sleep, very small eyelid openings may be obscured by eyelashes and go undetected.
The symptoms a person experiences depend on the severity of the condition and a person’s age. Because ocular lubrication mitigates the drying effect of nocturnal lagophthalmos, older adults are more likely to have symptoms due to age-related reduction in tear quality and production.
Nocturnal lagophthalmos symptoms are usually the worst in the morning and improve over the course of the day. Possible symptoms include:
- Dry eyes
- Sore or painful eyes
- A feeling of irritation
- Watery eyes
- Blurry vision
- Red eyes
- Eyes that feel scratchy, irritated and dry
- The sensation of having something “stuck” in your eye
- Sensitivity to light
- Tired eyes
For those with nocturnal lagophthalmos, the eye loses the protection of a closed lid and becomes dehydrated, causing the tear layer to evaporate and the eyes to become dry. Nocturnal lagophthalmos also reduces the eye’s ability to discharge contaminants such as dust and debris that fall into the eye during the night.
Risks and Complications
If left untreated, nocturnal lagophthalmos can significantly affect your eye health and compromise sleep. Over time, nocturnal lagophthalmos may damage the cornea from persistent dryness - a condition called keratitis - and increase the risk of corneal ulcers, perforation, and vision loss.
These disruptions can lead to conditions like xerophthalmia and keratopathies, which can eventually progress to vision loss. It could also affect your quality of sleep.
Studies have found that people who experience nocturnal lagophthalmos have poor sleep quality, mostly likely due to discomfort. Some research indicates that the light entering through open eyelids causes sleepers to awaken from visual stimulation.
In addition to protecting the eye from drying and irritation overnight, eyelids help block out light and visual input to the cerebral cortex. Light transmitted through closed eyelids can already contribute to circadian sleep disorders. It is suggested that open eyes during sleep may worsen this effect.
These contaminants can potentially lead to:
- Eye infections
- Corneal damage, such as corneal abrasion, sores and ulcers
- Eye dryness and irritation
- Poor quality sleep
- Loss of vision
Diagnosis of Nocturnal Lagophthalmos
Nocturnal lagophthalmos can be hard to diagnose on your own. If you’re having persistent eye symptoms, particularly dry-eye that is worse in the morning, it may be helpful to see a doctor for specialized testing.
Diagnosis of nocturnal lagophthalmos can be tricky because it occurs during sleep. Additionally, your eyelids may appear to fully close when you’re awake, or they may close enough that it seems like they are adequately sealed when they are not. Observation alone might not be enough to deliver a definitive diagnosis.
If a doctor suspects nocturnal lagophthalmos, they typically begin the diagnostic process by observing the eyes from a distance. They also thoroughly discuss symptoms, predisposing conditions, and family history with the person experiencing symptoms.
Based on the initial consultation, the doctor may recommend a slit lamp examination. This procedure uses a low-power microscope to examine structures in the eye. The doctor may also ask the person experiencing symptoms to blink, and use gloved hands to move the eyelids and check for signs of nerve dysfunction.
In these situations, an eye doctor will likely use the Korb-Blackie light test. This test involves shining a transilluminator light just above the eye, over the upper tarsal plate. If light leaks onto the cheek, it indicates the eyelid is not sealing correctly.
A special assessment is often done since this is an important component of developing a patient’s treatment plan.
A recent study explored the capabilities of artificial intelligence for diagnosing lagophthalmos. The software correctly classified still images of lagophthalmos patients about 93% of the time. While this technology is in its early phases, such software may greatly simplify diagnosis in the future.
Treatment Options for Nocturnal Lagophthalmos
The treatment given for nocturnal lagophthalmos varies depending on its cause and the severity of symptoms. It’s important to treat this condition early to prevent damage to the eye and tear film over time.
If possible, it is important to correct any underlying condition contributing to the problem. For example, a person with nerve damage might consult a neurologist, or someone with a thyroid disorder may require endocrine therapy. Sometimes, treating the underlying cause of your open eyes may help resolve this problem.
Nocturnal lagophthalmos treatment should also address the effects on the eye. Many symptoms can be improved with treatments that preserve moisture in the eyes.
The first goal of treating nocturnal lagophthalmos is to improve dry-eye and prevent keratitis. People experiencing symptoms may be given eye drops to provide lubrication for waking hours and an ointment for bedtime. Over-the-counter lubricant: Before you go to bed, apply an over-the-counter thick layer of lubricant to your eyes.
There are several simple, noninvasive ways to help keep your eyelids closed at night, such as:
- Using eyelid tape (applied over the eyelid from the cheek to the forehead, pulling up the cheek skin to keep the eye closed)
- Using eyelid weights (a tiny metal weight, usually gold, taped to the eyelid)
- Wearing fabric or moisture-preserving sleep masks
- Wearing an eye mask or goggles to protect the eyes from external debris and visual stimulation. These items are uniquely designed to generate moisture for the eyes while you sleep.
- Improving your sleep hygiene
- Adjusting sleep medication or alcohol intake
- Oil gland treatment
- Warm compresses
- A humidifier to counteract a dry environment. Using a humidifier, which provides a moisture-rich environment to prevent your eyes from drying out.
- Moisture-chamber goggles
If you’re diagnosed with nocturnal lagophthalmos, it may be appropriate to make adjustments to your sleeping environment to counteract its effects. Make sure the room is kept dark so that light does not enter and contribute to awakenings. Using a humidifier or moving your bed away from dry airflow can also lessen dry-eye.
People experiencing nocturnal lagophthalmos are encouraged to limit alcohol or sedatives before bed. It’s also important to keep the eyes clean and free of debris since insufficient lubrication increases the risk of infection. People with nocturnal lagophthalmos might find it helpful to practice blinking more frequently and fully during waking hours to ensure the eyes have sufficient moisture.
If conservative strategies do not help the eyelids seal or adequately treat symptoms, surgical options may be recommended. Surgical procedures may vary but can involve:
- Modifying the upper eyelid muscles
- Implanting weights in the eyelids. Your doctor might put a weighted implant in the eyelids to help your eyes close correctly.
- Expanding or tightening the eyelids
- Skin grafting
- Sewing the eyelids closer together
- Implanting tiny gold weights in the eyelids.
Although these approaches may sound drastic, they are generally well-tolerated and effective.
When to Seek Medical Advice
To prevent any long-term effects from nocturnal lagophthalmos, it’s important to consult an eye doctor early on. If your eyes are dry or watery, you have the persistent feeling of something stuck in your eye or you experience changes in your vision, contact your eye doctor to schedule an eye exam. Some symptoms of nocturnal lagophthalmos and dry eye disease overlap. There is also evidence of the two conditions being related. If you’re already seeking treatment for dry eye disease, consider whether nocturnal lagophthalmos could be a contributing factor.
Because nocturnal lagophthalmos sometimes signals an underlying condition, it is especially important to contact an eye doctor for a proper diagnosis and to receive prompt treatment. If nocturnal lagophthalmos is left untreated for an extended period, patients risk seriously damaging their eyes and vision. Getting a proper diagnosis and tailored treatment plan will help you get the quality shut-eye you need.
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