Managing an Eye Which Cannot Close Properly

Case Study: The GP and optometrist have important roles

Dr Charles Su

This picture is of a patient with a facial paresis. He is unable to close the right eye completely.
Of course, establishing a diagnosis and ensuring that causes such as intracranial pathology and neural infiltration with SCC is paramount, and neuro-imaging can be necessary.
Preventing damage to the ocular surface is also important.

Here are a few tips:

1. Make sure that there is no loss of corneal sensation. 

A drop of local anaesthetic should initially sting. The corner of a clean facial tissue touched onto the peripheral cornea should be felt by the patient, and even elicit a reflex blink. Loss of corneal sensation together with incomplete eye closure is an URGENT problem. First, because it means that two cranial nerves are involed (the trigeminal for sensation and the facial for motor loss), and therefore that a serious neurological problem or space occupying lesion needs to be sought. Second, because this combination makes it extremely likely that corneal ulceration will occur without detectable trauma. In many cases, these patients will need a tarsorrhaphy to protect their cornea.
Assuming that corneal sensation is not affected, further practical tips are:

2. Regular artificial drops EVEN WHEN THERE IS NO DISCOMFORT.

Prevention of dryness is the key. In the photo shown the patient has a good Bell’s Phenomenon. The eye rolls up on attempted closure, which protects the cornea. Even here, however, regular QID artificial tears, and ointment before sleep, is recommended.

3. Warn the patient that the ointment is messy …

and will block good vision for a few minutes, but use a thick oily ointment before bed, not just a gel. Poly Visc and Refresh Night Time ( Lacri Lube) are examples of ointments which should be liberally put into the lower lid fornix.

 4. A Moisture Chamber can reduce night time drying.

A large piece of clear cling wrap such as Glad Wrap, folded up into the size of a credit card, can be taped loosely over the eye region on the affected side with ordinary or paper tape, after placement of the ointment, before sleep, so that the passage of air over the partially open eyelids is reduced through the night. This is more effective than wearing a fabric eye patch with an elastic band, which can slip, and which is less impermeable.