Sleeping with eyes open, also known as nocturnal lagophthalmos, is a condition where a person’s eyes remain partially open during sleep. It can occur in healthy individuals or be a symptom of various neurological, ophthalmological or medical disorders. While the exact prevalence is unknown, it is estimated that around 20% of the population experiences episodes of open-eyed sleeping.
What causes sleeping with eyes open?
There are several factors that can lead to a person sleeping with their eyes open:
- Anatomical abnormalities – Facial paralysis or abnormalities in the shape of the eyelids or orbit can make complete eye closure difficult during sleep.
- Weakness of the orbicularis oculi muscle – This muscle controls eye closure. Weakness, such as from nerve damage, can prevent complete eye closure.
- Bell’s palsy – This condition causes facial paralysis which affects the orbicularis oculi muscle leading to incomplete eye closure.
- Floozy eyelids – Older individuals often develop floppy eyelids which are unable to close completely during sleep.
- Graves’ disease – An autoimmune disease that causes inflammation of eye muscles preventing full closure.
- REM sleep behavior disorder – This disorder causes loss of muscle atonia during REM sleep allowing motor behavior to occur when dreaming.
- Medications – Certain medications like antihistamines, decongestants, antidepressants and antipsychotics can cause muscle relaxation preventing complete closure of the eyelids.
- Dry eyes – Insufficient tear production or chronic inflammation can lead to the eyes opening during sleep to moisten the ocular surface.
- Brain damage – Damage to the facial nerve or brainstem can disrupt neural signals controlling eyelid closure.
For most healthy individuals, open-eyed sleeping occurs due to the normal fluctuations in the stages of sleep. During light sleep or transitional phases, the muscles supporting eye closure relax and allow the eyes to partially open before entering deeper sleep stages. This is considered a normal variation.
What are the symptoms of nocturnal lagophthalmos?
The main symptom of sleeping with eyes open is obvious – a person’s eyelids remain partially or fully open while asleep. Usually both eyes are affected. Associated symptoms can include:
- Dryness of the eyes
- Blurry vision upon waking
- Red or irritated eyes
- Excessive tearing
- Sandy or gritty sensation in the eyes
- Eye pain or soreness
- Light sensitivity
- Eye fatigue
- Recurrent eye infections
These symptoms occur due to greater exposure of the eyes in the open state leading to tear film evaporation and corneal drying. Over time, this can cause abrasions of the corneal surface.
What are the risks of sleeping with eyes open?
Frequent and severe episodes of open-eyed sleep can lead to complications:
- Corneal abrasions – Drying of the corneal surface makes it more vulnerable to abrasions while sleeping which are very painful.
- Corneal ulcers – Long term drying can cause deficiencies in the corneal epithelium leading to ulceration which can progress to perforation of the cornea if untreated.
- Corneal scarring – Chronic corneal irritation promotes inflammation which causes permanent scarring.
- Corneal neovascularization – The cornea receives nutrients and oxygen directly from tears. Dryness triggers growth of blood vessels into the cornea negatively impacting vision.
- Infections – Bacteria have greater access to the eyes when lid closure is incomplete, increasing the risk of infections like bacterial conjunctivitis.
- Vision loss – Severe corneal damage from repeated abrasions, ulcers and scarring can reduce visual acuity and lead to blindness in severe untreated cases.
Individuals with lagophthalmos are also more prone to symptoms of dry eyes during waking hours as the condition is frequently chronic. Other risks include light sensitivity, eye strain, headaches and difficulty wearing contact lenses.
Who is at risk of sleeping with eyes open?
Nocturnal lagophthalmos can affect individuals of any age and gender. Those more likely to be affected include:
- People with facial nerve paralysis, such as from Bell’s palsy
- Individuals with reduced facial muscle tone, like in myasthenia gravis
- People taking medications that affect muscle tone like benzodiazepines
- Those with hypothyroidism resulting in eyelid retraction
- Individuals with Graves’ disease, an autoimmune disorder
- People with REM sleep behavior disorder
- Those with floppy eyelid syndrome, often older adults
- Patients with chronic dry eyes
- Individuals with brain tumors or nerve damage affecting eyelid closure
Genetics may play a role as some families demonstrate a hereditary predisposition to incomplete eyelid closure. People of Asian descent appear to have a higher risk of developing nocturnal lagophthalmos.
How is sleeping with eyes open diagnosed?
A physician will first perform a physical exam of the eyes to check for signs of dryness, corneal abrasions or infection. They will examine the eyelids and facial nerves for abnormalities and tone. Typical diagnostic tests include:
- Slit lamp exam – Provides magnification to closely inspect the eyelids, cornea and tear film.
- Schirmer test – Measures tear production by placing paper strips under the eyelids.
- Tear breakup time – Evaluates tear film stability by measuring time until tears evaporate.
- Corneal staining – Uses fluorescein dye to reveal corneal damage.
- Facial nerve assessment – Tests movement and reflexes in facial muscles.
- Imaging – CT or MRI scans help identify facial nerve or brain abnormalities.
- Polysomnography – Records sleep patterns and detects conditions like sleep apnea.
Your medical history, current medications and description of symptoms provides important information to determine the cause of open-eyed sleeping. Blood tests may also be ordered to check for thyroid disorders or other medical conditions.
What is the treatment for nocturnal lagophthalmos?
Treatment focuses on protecting the eyes and managing any underlying medical conditions:
- Eyelid hygiene – Cleaning debris from eyelid margins helps reduce inflammation and infection risk.
- Warm compresses – Helps loosen oil secretions to prevent evaporative dry eye.
- Artificial tears – Lubricating drops during the day relieves dryness and irritation.
- Gels or ointments – Thicker lubricants applied at bedtime coat the eyes and slow evaporation.
- Humidifier – Adds moisture to bedroom air to prevent drying.
- Medications – Prescription cyclosporine drops help reduce corneal inflammation. Oral cholinergics improve eyelid closure in some neurological disorders.
- Facial stimulation – Exercises to strengthen orbicularis oculi muscle tone may improve eyelid closure.
- Surgery – Eyelid implants or procedures to tighten lax muscles may be required in severe cases unresponsive to other treatments.
Identifying and addressing any underlying causes such as facial paralysis, sleep disorders or medication side effects is also important.
What is the prognosis for people who sleep with eyes open?
The prognosis depends on the severity of the lagophthalmos and presence of any related conditions. Mild cases can often be managed with basic dry eye treatments to prevent complications. More significant open-eyed sleeping requires consistent therapy to protect vision.
Facial paralysis from Bell’s palsy or nerve damage causing eyelid opening often resolves over several weeks or months. Other underlying disorders like Graves’ disease may be chronic requiring ongoing treatment. Surgery to correct anomalies in eyelid structure can be curative if other therapies fail.
With proper care to lubricate and shield the eyes at night and treating any medical conditions, most patients respond well and can maintain good corneal health and vision. However, severe lagophthalmos can lead to vision loss if corneal damage is not addressed promptly. Regular eye exams are important to monitor for problems.
Overall the prognosis for sleeping with eyes open is good with appropriate management. Temporary cases related to medication use or REM disorders often resolve fully. Permanent neural damage and structural deficits may require long term therapy but visual outcomes can still be good.
How can sleeping with eyes open be prevented?
It’s not always possible to prevent nocturnal lagophthalmos, especially if due to an underlying medical disorder. However, the following methods may help reduce episodes of open-eyed sleep:
- Treating dry eyes – Restoring normal tear film helps protect the eyes when open at night.
- Managing allergies – Controlling allergic eye conditions reduces inflammation that can cause opening.
- Warm compresses – Can help loosen meibomian gland secretions to prevent evaporative dryness.
- Eyelid hygiene – Keeping lids clean prevents debris buildup that can impede full closure.
- Avoiding irritants – Reducing smoke, perfumes or chlorinated water exposure prevents drying.
- Checking medications – Discussing options to discontinue or replace drugs causing muscle relaxation.
- Humidifier – Can compensate for moisture lost through open eyes during sleep.
- Sleep position – Avoiding sleeping completely flat may allow better eye closure.
- Managing facial paralysis – Addressing causes through physical therapy or surgery if possible.
Maintaining good lid hygiene and ocular surface health is key. Report any episodes of eye irritation, pain or redness during the day to an eye doctor as soon as possible. Seek evaluation for any persistent open-eyed sleeping.
Conclusion
Sleeping with eyes open affects up to 20% of adults for periods of time. While usually benign, chronic corneal exposure can threaten vision. Causes range from natural sleep transitions to facial paralysis. Diagnosis involves a comprehensive eye exam and tests for underlying disorders. Treatment aims to shield the eyes and correct any pathologic process preventing complete closure during sleep. Most patients respond well to lubricating drops and gels with resolution of temporary causes. Overall the prognosis is positive with consistent protection of the corneas, but severe cases may risk blindness without aggressive therapy.