Ocular irritation, burning, foreign body sensation, tearing, and redness of one or both eyes. Usually worse in the morning.

Critical

Inadequate blinking or closure of the eyelids, leading to corneal drying. Punctate epithelial defects are found in the lower one-third of the cornea or as a horizontal band in the region of the palpebral fissure (see Figure 4.5.1).

Figure 4.5.1: Exposure keratopathy stained with fluorescein.

Other

Conjunctival injection and chemosis, corneal erosion, infiltrate or ulcer, eyelid deformity, or abnormal eyelid closure.

• Seventh cranial nerve palsy: Orbicularis oculi weakness (e.g., Bell palsy). See 10.9, Isolated Seventh Nerve Palsy.

• Sedation or altered mental status.

• Eyelid deformity (e.g., ectropion or eyelid scarring from trauma, eyelid surgery such as excisional procedure, chemical burn, or herpes zoster ophthalmicus).

• Nocturnal lagophthalmos: Failure to close the eyes during sleep.

• Proptosis (e.g., due to an orbital process such as thyroid eye disease). See 7.1, Orbital Disease.

• After ptosis repair or blepharoplasty procedures.

• Floppy eyelid syndrome. See 6.5, Floppy Eyelid Syndrome.

• Poor blink (e.g., Parkinson disease, neurotrophic cornea).

1. History: Previous Bell palsy or eyelid surgery? Thyroid disease?

2. Evaluate eyelid closure and corneal exposure. Ask the patient to close his or her eyes gently (as if sleeping). Assess Bell phenomenon (the patient is asked to close the eyelids forcefully against resistance; abnormal when the eyes do not rotate upward). Check for eyelid laxity.

3. Check corneal sensation before instillation of anesthetic drops. If sensation is decreased, there is greater risk for corneal complications and the patient may need further management for neurotrophic keratopathy. See 4.6, Neurotrophic Keratopathy.

4. Slit-lamp examination: Evaluate the tear film and corneal integrity with fluorescein dye. Look for signs of secondary infection (e.g., corneal infiltrate, anterior chamber reaction, severe conjunctival injection).

5. Investigate any underlying disorder (e.g., etiology of seventh cranial nerve palsy).

Prevention is critical. All patients who are sedated or obtunded are at risk for exposure keratopathy and should receive lubrication according to the following recommendations.

In the presence of secondary corneal infection, see 4.12, Bacterial Keratitis.

1. Correct any underlying disorder.

2. Preservative-free artificial tears q2–6h. Punctal occlusion with plugs may also be considered.

3. Lubricating ointment q.h.s. to q2h.

4. Consider eyelid taping or patching q.h.s. to maintain the eyelids in the closed position. If severe, consider taping the lateral one-third of the eyelids closed (leaving the visual axis open) during the day. Taping is rarely definitive but may be tried when the underlying disorder is thought to be temporary.

5. A potential in-office procedure includes placement of self-retained amniotic membrane tissue (e.g., sterilized, dehydrated amniotic  membrane covered by a bandage soft contact lens or frozen, specialized plastic ring–mounted amniotic membrane such as Prokera).

6. When maximal medical therapy fails to prevent progressive corneal deterioration, one of the following surgical procedures may be beneficial:

   • Partial tarsorrhaphy (eyelids sewn or glued together).

   • Eyelid reconstruction (e.g., for ectropion).

   • Eyelid gold or platinum weight implant (e.g., for seventh cranial nerve palsy).

   • Orbital decompression (e.g., for proptosis).

   • Conjunctival flap, sutured/glued amniotic membrane graft, or Descemet membrane graft (for severe corneal decompensation if the preceding fail).

Reevaluate every 1 to 2 days in the presence of corneal ulceration. Less frequent examinations (e.g., in weeks to months) are required for less severe corneal disease.