Dry eye therapy can’t work until we target nocturnal lagophthalmos

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

By Tracy Doll, OD, FAAO

In my dry eye disease (DED) referral practice, one very specific problem can sabotage DED management: incomplete eyelid seal at night, or nocturnal lagophthalmos (NL). Patients often don’t know that they have NL, and the treatment regimen can be completely new to them. NL is such a problem for these patients that if I don’t get it under control, then we can’t effectively manage DED, and my patients will continue to be miserable.

In patients who have a good lid seal, 6 to 8 hours of sleep each night allows the ocular surface to recover from daytime exposure and to be prepared for a new day. But about 5% of adults¹ and over 60% of patients with symptomatic DED² have moderate to severe lid seal compromise. NL exacerbates signs and symptoms of DED and negatively affects patients’ quality of sleep.³

Although NL is a common contributor to DED, many eye care providers are unaware of how to diagnose and treat incomplete lid seal at night. Doctors who are not treating NL might be frustrated that DED therapies aren’t working very well for their patients. I have some tips to address NL and make DED management more effective.

Diagnose NL Early

The last thing I want to do is spend months working with patients to manage their DED, only to find that their therapies don’t work and belatedly diagnose NL. Unfortunately for my referral patients, that often has already happened. The simple solution is to make NL diagnosis a routine part of the DED exam.

The first screening step is the easiest: I ask patients when their eyes feel the worst. If they say the morning and there is no evidence of a corneal dystrophy, then they’re likely sleeping with their eyes open. The second confirmatory step is the Korb-Blackie light test.⁴ With the patient slightly reclined in a dark room with their eyes closed and relaxed, I place a transilluminator or penlight against the upper eyelids. If light is seen escaping between the eyelids, then the seal is incomplete. I use this quick, standardized test for all my DED workups, and it saves me months of trial and error trying to optimize a surface that is exposed for 6 to 8 hours each night.

Education is easy for NL. As I’m doing the lid seal test, I explain that I can see how their eyes do not completely shut. This incomplete closure can be top to the bottom like a classic “open eye” or like an “over-bite” where the exposure is front to back. This information helps them make sense of why they don’t feel good in the morning. They also hear that I have solutions for them.

Signs and Related Conditions

The primary symptom of NL is feeling dry and gritty in the morning. It’s also important to be aware of other signs and risk factors of NL, both for diagnosis and to offer explanations to patients. Some of those factors include:

• Age: Advancing age can cause lid laxity and ectropion, which can cause NL. Be aware during light testing that the lid seal may look complete, but lax eyelids can move if patients turn on their side.
• Staining: Corneal staining in a smile pattern on the lower part of the cornea can be indicative of NL. However, we can’t rely on staining alone for diagnosis. If the patient is a good healer, the damage can lessen or heal completely before an afternoon appointment. The light test is more accurate.
• Prior plastic surgery: For patients who have recently had a browlift or blepharoplasty, healing tissue can be tight and prevent the eyelids from completely closing. It’s important to make sure they’re getting good coverage as the eyelids fully heal. When I talk to the patient, I’m careful to normalize the healing process, so the patient does not think exposure is a surgical error. I educate that scar tissue is tighter and that is expected. Patients simply need a better regimen at night to cover over the healing so they can look good and feel good.
• Anatomical differences: I treated a set of 13-year-old identical triplets whose parents had repeatedly taken them to doctor for help with red, irritated eyes. They had identical incomplete 3-mm gaps in their eyelid seals. This was clearly an inherited anatomical difference. When asked, all 3 confirmed the morning was the worst time for symptoms.
• Concurrent eyelid disease states: Eyelid edema from concurrent eczema or ocular rosacea can lead to incomplete lid seal, with an “over-bite” appearance of the upper lid extended too far over the lower lid. Patients may need lid seal support while these conditions are being managed.
• History of certain conditions: Certain systemic health conditions are positively associated with NL. Ehler-Danlos syndrome and hypermobility conditions can lead to floppy eyelid syndrome, where the lid structure is loose.⁵ Many of my patients with NL also have obstructive sleep apnea (OSA)—in fact, it’s become a bit of a red flag. The reason may lie in the patient’s connective tissue. Both the airway and eyelids have connective tissue that is altered by hypoxic inflammation and reflected in OSA.

Management for NL

NL can vary in severity, correlated directly to the size of the exposure. Regardless of severity, I can treat patients with a nightly routine that handles the problem. Therapies do 2 things:

1. Seal the eyelids. We have to get the eye protected at night, which means sealing the eyelid. If NL is a minor problem with a small sliver of light showing through and slight discomfort in the morning, I use preservative-free iVIZIA Lubricant Eye Gel (Thea), which is designed for nighttime DED relief. It’s very popular with my mild lid seal patients who are pleased with the results and the fact that they can be achieved with a comfortable, easy-to-use eye drop. If the problem is more pronounced, I recommend Optase Hylo Night (Optase), a preservative-free ointment with vitamin A to improve corneal cell integrity.
2. Cover the eyes. Once patients have applied the eye drops or ointment as instructed, I want them to cover their eyes while they sleep to further protect their eyes from blowing air. One option is a silk wrap mask, which can be found online as well as in many stores. Silk or similar fabric is gentle on the eyelashes, and these masks are less likely to apply pressure or dislodge. I’m also a huge fan of SleepTite, SleepRite gentle eye-shaped lid closure stickers (Ophthalmic Resource Partners). Anyone can use them, but I find they exceed a standard mask for my patients with a lot of exposure, such as those with floppy eyelid syndrome, overdone blepharoplasty, and patients with sleep apnea who use a CPAP machine. I’ve avoided masks with eye cups because the shape keeps air around the eyes.

When patients return for follow-up 1 month after starting this regimen, they report that they’re waking up far more comfortable with less gritty, red, and watery eyes. I see corneal healing, less inflammation, and better visual acuity. Because patients are no longer starting the day with a symptomatic exposure problem and then playing catch-up all day, their standard DED therapies can finally work. This is only possible when we target the nighttime lid seal.

References

1. DelRosso LM, Lehnert D, Chen ML. When sleeping with eyes closed is optional. J Clin Sleep Med. 2019;15(10):1551-1553. doi:10.5664/jcsm.8002
2. Korb D, Blackie C, Nau A. Prevalence of compromised lid seal in symptomatic refractory dry eye patients and asymptomatic patients. Invest Ophthalmol Vis Sci. 2017;58:2696.
3. Takahashi A, Negishi K, Ayaki M, Uchino M, Tsubota K. Nocturnal lagophthalmos and sleep quality in patients with dry eye disease. Life (Basel). 2020;10(7):105. doi:10.3390/life10070105
4. Blackie CA, Korb DR. A novel lid seal evaluation: the Korb-Blackie light test. Eye Contact Lens. 2015;41(2):98-100. doi:10.1097/ICL.0000000000000072
5. Gerner EW. Lax lids are red flags. Review of Ophthalmology. June 10, 2019. Accessed November 21, 2025. https://www.reviewofophthalmology.com/article/lax-lids-are-red-flags

Tracy Doll, OD, FAAO, is coordinator of ocular surface services at Sunset Eye Clinic in Beaverton, Oregon. Disclosures: Ophthalmic Resource Partners.