Lagophthalmos: Clinical Guidelines

List of Abbreviations

DED – dry eye disease

MRI – magnetic resonance imaging

CT – computed tomography

NSAIDs – nonsteroidal anti-inflammatory drugs

PTFE – polytetrafluoroethylene

CNS – central nervous system

Terms and Definitions

Lagophthalmos – incomplete eyelid closure

Eyelid retraction – displacement of the eyelid toward the orbital margin (upper or lower)

Exophthalmos – anterior displacement of the eyeball

Thyroid eye disease – inflammation and edema of retrobulbar soft tissues occurring in the setting of autoimmune thyroid pathology

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Lagophthalmos – (from Greek lagoos — hare, ophthalmus — eye) – impairment of eyelid closure function, incomplete closure of the eyelids.

The main causes of lagophthalmos development are facial nerve damage or the presence of mechanical factors preventing complete eyelid closure. A separate condition is physiological lagophthalmos.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Based on etiopathogenetic features, lagophthalmos is classified into paralytic, cicatricial, and physiological (depending on the anatomical shape of the palpebral fissure) [1, 2, 3, 4, 5, 6].

The most common cause of lagophthalmos is facial nerve damage (paralytic lagophthalmos) [5, 6, 7].

Facial nerve pathology can be caused by the following reasons.

Bell's palsy—idiopathic facial paralysis (facial neuropathy)—is the most frequent cause of paralytic lagophthalmos. The condition typically has a sudden onset, is characterized by unilateral involvement, and frequently resolves spontaneously. Facial nerve damage is often associated with a prior viral infection [8, 9].

Less common infectious causes of facial nerve palsy include mumps, influenza, encephalitis, herpes zoster, chickenpox, poliomyelitis, diphtheria, botulism, leprosy, cat-scratch disease, sarcoidosis, Lyme disease (tick-borne borreliosis), Ramsay Hunt syndrome, and Guillain-Barré syndrome [10, 11, 12].

One of the clinical manifestations of Lyme disease is cranial neuropathy associated with the dissemination of the causative agent of this infectious disease, the spirochete Borrelia, to various organs and systems. The cranial nerve VII is most commonly involved in the inflammatory process, leading to facial paralysis. Neuritis of the oculomotor and optic nerves is accompanied by impaired convergence and decreased visual acuity [13, 14].

Ramsay Hunt syndrome, caused by a herpetically induced (herpes zoster) lesion of the geniculate ganglion, begins with the appearance of a unilateral vesicular rash in the auricle region and facial neuropathy [15, 16].

Guillain-Barré syndrome is an acute autoimmune polyradiculoneuropathy developing after a preceding infection, manifesting as flaccid paresis and bilateral facial paralysis [17, 18].

Neoplasms of the central nervous system ( cerebellopontine angle tumors), acoustic neuromas and facial schwannomas, diseases of the parotid salivary gland, and others can also cause facial nerve involvement [19, 20, 21].

Impairment of n. facialis function is a frequent complication following neurosurgical interventions (iatrogenic paralysis) [22].

Congenital developmental anomalies. Möbius syndrome (facial diplegia) is a genetically determined condition characterized by congenital hypoplasia of the cranial nerve nuclei V, VI, VII, IX, and XII, leading to impaired function of the facial and abducens nerves. The disease manifests as a lack of facial expression, incomplete eyelid closure, strabismus, impaired suckling, swallowing, articulation, motility, and other neurological symptoms. This pathology is caused by autosomal dominant, autosomal recessive, and X-linked inheritance [23].

Acute cerebrovascular accidents, aneurysms. Due to the peculiarities of the blood supply to the n. facialis from the anterior inferior cerebellar artery and the geniculate ganglion region, acute ischemia of this brain area causes facial paralysis [24, 25].

Traumatic injury to the facial nerve. Facial trauma, middle ear trauma, skull base fractures (petrous part of the temporal bone), or mandibular fractures can cause damage to both the trunk and individual branches of the facial nerve [24, 25, 26].

Cicatricial lagophthalmos. The presence of cicatricial eyelid deformity also frequently leads to lagophthalmos. Causes may include mechanical injuries, chemical and thermal burns, radiation damage, cicatricial pemphigoid, Stevens-Johnson syndrome, Lyell syndrome, ichthyosis, and eyelid surgical procedures (chalazion removal, tumor excision, aesthetic blepharoplasty, upper eyelid ptosis correction, etc.). In cicatricial lagophthalmos, the extent of palpebral fissure non-closure depends on the tissue defect area and the severity of impaired eyelid excursions [3, 27, 28, 29].

Lagophthalmos may result from upper and/or lower eyelid retraction in patients with thyroid eye disease [30].

Physiological lagophthalmos can occur in individuals without any pathology of the eyelids and surrounding tissues; this condition is most commonly observed with an epicanthus or typical Asian palpebral fissure shape. Incomplete closure of the palpebral fissure occurs during sleep (nocturnal lagophthalmos) [31].

Lagophthalmos due to lower eyelid atonia in elderly patients develops secondary to the loss of tissue elasticity and is characterized by lower eyelid prolapse (ptosis) and ectropion of the lacrimal punctum [32, 33].

1.3 Epidemiology of the Disease or Condition

The prevalence of nocturnal lagophthalmos ranges from 1.3 to 23% depending on the population and increases significantly under sedation in intensive care settings, reaching 21–75% [34].

The incidence of lagophthalmos following surgical treatment of aponeurotic blepharoptosis reaches 11% [35].

Facial nerve palsy ranks second among peripheral nervous system disorders and first among cranial neuropathies. Annually, 20 to 30 cases of facial paralysis per 100,000 population are detected, equally among women and men [19, 36].

The prevalence of Möbius syndrome is 1 case per 150,000 newborns [37].

1.4 Features of Coding the Disease or Condition

• H02.2 – Lagophthalmos

1.5 Classification of the disease or condition

Clinical classification

Classification of lagophthalmos by severity (based on the degree of lagophthalmos):

Mild grade. Lagophthalmos up to 3.0 mm. The palpebral fissure on the affected side is noticeably wider compared to the healthy contralateral side. Eyelid closure is possible, but incomplete, which is especially noticeable during sleep.

Moderate grade. Lagophthalmos up to 5.0 mm. Eyelid closure is difficult, and the palpebral fissure remains partially open. The conjunctiva and cornea are exposed to external irritants, leading to chronic conjunctivitis, keratitis, dry eye syndrome (DES), and partial corneal opacity.

Severe grade. Lagophthalmos greater than 5.0 mm. Eyelid closure is completely impaired. The absence of the protective function of the eyelids can lead to severe consequences, such as a corneal ulcer with a threat of perforation or the formation of a vascularized corneal leucoma [1, 5, 38].

1.6 Clinical presentation of the disease or condition

Clinical presentation of paralytic lagophthalmos. Facial nerve paralysis is characterized by atonia of the facial muscles on the affected side, muscle hypertonus on the unaffected (healthy) side, lower eyelid ectropion and lagophthalmos, absence of blinking movements, pooling of tears (epiphora/tear pooling), corneal pathology (DES, keratitis, erosion, corneal ulcer, vascularized leucoma), and decreased visual function [6, 11, 39].

Functional insufficiency of the eyelids in facial nerve palsy manifests as impaired closure (lagophthalmos) and blinking, as well as atonia and ectropion of the lower eyelid. This leads to excessive tear film evaporation and exposure keratopathy. The absence of normal orbicularis oculi muscle function against the background of long-standing facial nerve palsy promotes upper eyelid retraction, which increases the severity of lagophthalmos. Neurotrophic disorders and reduced basal tear secretion are additional unfavorable factors that exacerbate the condition of the conjunctiva and cornea. The most dangerous complications of lagophthalmos are: severe corneoconjunctival xerosis, keratitis, opacity, erosion, and corneal ulceration. The formation of a vascularized leucoma with vision loss, perforation of a corneal ulcer with the development of endophthalmitis, and loss of the eye as an organ are the most severe consequences of past inflammatory processes [3, 6, 7, 21, 32].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for diagnosing lagophthalmos: unilateral or bilateral incomplete eyelid closure, which, when eyelids are closed, forms a fissure 1 mm or more in width.

2.1 Complaints and Anamnesis

Comments. Diagnostics begins with taking a medical history: determining the onset time, nature of the disease (congenital, acquired), preceding events (trauma, burn, prior stroke, acute infectious disease, neurosurgical intervention, acute allergic reaction to NSAIDs, etc.), and identifying hereditary factors.

2.2 Physical Examination

Comment: a neurological consultation is necessary to assess the function of cranial nerves, which helps rule out lagophthalmos as a manifestation of, among other things, a congenital developmental anomaly.

2.3 Laboratory Diagnostics

Not informative for this pathology.

2.4 Instrumental Diagnostics

Comments: visual acuity testing reveals a decrease in visual acuity as a consequence of exposure keratopathy.

Comments: biomicroscopy of the eye, as a diagnostic method, makes it possible to assess the condition of the anterior segment of the eye and detect changes in the conjunctiva and cornea that may accompany lagophthalmos.

Comments: the method has adjunctive value in assessing the condition of the eye and its refractive media. Vital dyes must be used to detect corneal epithelial defects.

2.5 Other Procedures

Comment: the study is performed using a Hertel mirror exophthalmometer. Normally, the protrusion of the eyeball from the orbit is 14–18 mm, and the asymmetry in the position of paired eyes should not exceed 1–2 mm [43].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Comment: the use of pharmacotherapy is advisable only at the initial stage, as an adjunctive method prior to surgical treatment and in the postoperative period, as well as in cases of mild or physiological lagophthalmos. For the treatment of concomitant dry eye disease and corneal xerosis, the continuous use of artificial tear preparations and other indifferent preparations (S01XA20) is indicated. To prevent the development of dystrophic changes in the conjunctiva and cornea, the use of gel and ointment keratoprotectors is indicated (S01XA other ophthalmological drugs). The prescription of antibiotics is advisable when there is a risk of infectious complications against the background of de-epithelialization (chronic conjunctivitis, keratitis, erosion, corneal ulcer).

As a palliative method, temporarily fixing the eyelid in the correct position is also possible using adhesive strips (non-woven medical eye tapes) [11].

3.2 Surgical Treatment

Comments: ulceration and the risk of corneal perforation are indications for emergency blepharorrhaphy and tarsorrhaphy. Indications for elective surgical treatment of paralytic lagophthalmos include facial nerve palsy lasting more than six months and its irreversibility, exposure keratopathy with a potential risk of corneal ulceration and perforation, and paralytic lower eyelid ectropion.

Comments: indications for surgical treatment of lagophthalmos associated with age-related changes in the eyelid ligamentous apparatus include pronounced atonia, prolapse, and senile lower eyelid ectropion, as well as impaired normal tear drainage (epiphora and pooling of tears).

Comments. Indications for elective surgical treatment of cicatricial lagophthalmos include cicatricial deformity, shortening, or ectropion of the eyelid(s), and the risk of corneal opacity.

Post-burn lagophthalmos is characterized by cicatricial changes in the eyelid skin. Cicatricial traction leads to deformation of the tarsal plate, shortening, and ectropion of the eyelids. Correction of lagophthalmos in this case is possible by replenishing the skin deficit of the upper and lower eyelids using a free skin graft [3].

Permanent blepharorrhaphy for a prolonged period (6 months) is necessary to prevent recurrence of lagophthalmos. Suitable suture materials include: sterile alletendon threads for plastic ophthalmic surgery, sterile synthetic absorbable surgical threads with and without atraumatic needles, and other materials [42, 58, 68].

In the postoperative period, depending on indications, the following groups of medications are prescribed: instillations of antimicrobial drugs, S01XA20 artificial tears and other indifferent preparations, and S01XA other drugs used in ophthalmology for keratoprotection.

3.3. Other treatment

- not applicable

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments. Dynamic follow-up of patients with lagophthalmos is carried out during a follow-up visit (examination, consultation) by an ophthalmologist B01.029.002 and a follow-up visit (examination, consultation) by a neurologist B01.023.001.

5. Prevention and Dispensary Observation

6. Organization of Medical Care

Medical care for lagophthalmos is provided on a scheduled basis only in the absence of sight-threatening corneal pathology. A corneal ulcer, including one with a risk of perforation, is an indication for urgent referral of the patient for inpatient treatment.

Primary pre-medical health care for lagophthalmos is provided by medical workers with secondary medical education; primary medical health care for lagophthalmos is provided by district pediatricians and general practitioners (family physicians). When signs of lagophthalmos are detected, medical workers with secondary medical education, district pediatricians, and general practitioners (family physicians) refer patients for a consultation with an ophthalmologist. For lagophthalmos, primary specialized health care is provided by an ophthalmologist.

According to Order of the Russian Ministry of Health No. 211n dated April 14, 2025, "On the procedure for conducting preventive medical examinations of minors", during medical examinations of minors, including upon admission to educational institutions and during their studies, an ophthalmologist examines children at the age of 1 month, 12 months, 3 years, 6 years, 7 years, 10 years, 13 years, 15 years, 16 years, and 17 years.

Adults with lagophthalmos are examined by an ophthalmologist upon referral from a neurologist and doctors of other specialties, as well as during preliminary and periodic medical examinations upon employment and during employment in accordance with departmental regulatory acts and/or in accordance with Order of the Ministry of Labor No. 988n and the Russian Ministry of Health No. 1420n dated December 31, 2020, "On approval of the list of harmful and (or) hazardous production factors and jobs, the performance of which requires mandatory preliminary medical examinations upon admission to work and periodic medical examinations", and Order of the Russian Ministry of Health No. 29n dated January 28, 2021, "On approval of the procedure for conducting mandatory preliminary and periodic medical examinations of workers provided for in part four of article 213 of the Labor Code of the Russian Federation, the list of medical contraindications to carrying out work with harmful and (or) hazardous production factors, as well as jobs for which mandatory preliminary and periodic medical examinations are carried out".

Congenital and acquired lagophthalmos are also detected when patients (adults and children) independently apply to the ophthalmology office in the serviced area with complaints of changes in eyelid position.

The ophthalmologist of the ophthalmology office provides: consultative, diagnostic, and therapeutic care; in the presence of medical indications, refers patients for a consultation with an ophthalmic surgeon on a scheduled basis or for emergency inpatient treatment in a pediatric or adult ophthalmology department.

Indications for hospitalization in a medical organization include congenital and acquired lagophthalmos in children and adults. Patients are referred to a 24-hour or day hospital for surgical treatment. Medical care for children with lagophthalmos can only be provided in a 24-hour hospital setting.

An indication for discharging a patient from a medical organization is the completion of the planned inpatient treatment.

7. Additional Information

Lagophthalmos management involves two main tasks: first, prevention and treatment of threatening corneal pathology; second, selection of the optimal surgical method. When choosing the surgical treatment tactics, it is necessary to take into account the etiology of the disease (causes of development).

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Galimova, Venera Uzbekovna, MD, Professor, "Association of Ophthalmologists" LLC;

2. Golubev, Sergey Yuryevich, PhD, "Association of Ophthalmologists" LLC;

3. Nuraeva Aigul Bulatovna, MD, "Association of Ophthalmologists" LLC;

4. Potemkin Vitaly Vitalievich, MD, "Association of Ophthalmologists" LLC;

5. Filatova Irina Anatolievna, MD, Professor, "Association of Ophthalmologists" LLC.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Methods used for collecting/selecting evidence: searching electronic databases; analysis of modern scientific developments on the problem of astigmatism in Russia and abroad; synthesis of practical experience of Russian and foreign colleagues.

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its reliability. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations derived from it.

A preliminary version of these guidelines was reviewed by independent experts who were asked to comment primarily on whether the interpretation of the evidence underlying the recommendations is reliable and accessible to practicing physicians and patients.

Comments were received from ophthalmologists specializing in oculoplastic surgery and primary care physicians regarding the clarity of presentation and the importance of the recommendations as a working tool in daily medical practice.

Comments received from experts were carefully systematized and discussed by the chairs and members of the working group. Every item was discussed. Changes and additions recommended as a result of the discussion were incorporated into the text of the guidelines.

Target audience for these clinical guidelines:

1. Ophthalmologists;

2. General practitioners (family physicians);

3. Pediatricians;

4. Urban (district) pediatricians;

5. District pediatricians;

6. Neurologists, neurosurgeons, maxillofacial surgeons.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GoR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)

Procedure for updating clinical guidelines

The update mechanism for clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Order of the Russian Ministry of Health No. 442n dated October 25, 2012, "On Approval of the Procedure for Providing Medical Care to Children with Diseases of the Eye, Its Adnexa, and Orbit."

2. Order of the Russian Ministry of Health No. 902n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to Adults with Diseases of the Eye, Its Adnexa, and Orbit" (as amended).

3. Order of the Russian Ministry of Health No. 203n dated April 4, 2025, "On Approval of Criteria for Assessing the Quality of Medical Care."

4. Order of the Russian Ministry of Health No. 211n dated April 14, 2025, "On Approval of the Procedure for Minors Undergoing Preventive Medical Examinations, Accounting Form No. 030-PO/u 'Minor's Preventive Medical Examination Card', the Procedure for Its Maintenance, as well as the Form of Branch Statistical Observation No. 030-PO/o 'Information on Preventive Medical Examinations of Minors', and the Procedure for Its Completion."

5. Order of the Russian Ministry of Labor No. 988n and the Russian Ministry of Health No. 1420n dated December 31, 2020, "On Approval of the List of Harmful and (or) Hazardous Occupational Factors and Jobs Involving Mandatory Preliminary Medical Examinations upon Employment and Periodic Medical Examinations."

6. Order of the Russian Ministry of Health No. 29n dated January 28, 2021, “On approval of the procedure for mandatory preliminary and periodic medical examinations of workers provided for in part four of Article 213 of the Labor Code of the Russian Federation, the list of medical contraindications to performing work with hazardous and (or) dangerous production factors, as well as work during which mandatory preliminary and periodic medical examinations are carried out.”

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Lagophthalmos – (from Greek –  lagoos – hare, ophthalmus – eye) – impairment of the eyelid closure function.

The main causes of lagophthalmos are facial nerve lesions and various factors preventing eyelid closure.

The patient should be aware that if palpebral fissure non-closure is present, it is necessary to consult an ophthalmologist. In the absence of corneal pathology, hygiene, artificial tears, and other indifferent preparations as indicated are sufficient. If corneal pathology is present, surgical treatment should be planned.

The type of surgical treatment is determined by the attending physician based on indications. After surgery, follow-up with an ophthalmologist is usually required, along with the continued use of artificial tears and other indifferent preparations used in ophthalmology for keratoprotection.