We spend about a third of our lives sleeping, and while the exact purpose of sleep is not known, what is known is that we all need it. Usually, to go to sleep, one of the first things we do is close our eyes. While this act most likely helps us to both fall asleep and maintain sleep, it is also a way to help protect the ocular surface during sleep. When this process of closing and keeping our eyes closed during sleep is interrupted, it can contribute to the development of a number of eye disorders and also add to the signs and symptoms associated with dry eye disease. Nocturnal lagophthalmos (incomplete eyelid closure during sleep), facial nerve palsy (most commonly Bell’s palsy), floppy eyelid syndrome (everted eyelids during sleep), and sleep apnea are all conditions that have a link with both eye- and sleep- disorders. Protecting the surface of the eyes during sleep can have an impact in the management of these medical conditions as well improving daytime ocular comfort and health. Applying a long-lasting, lubricating ointment before going to bed, such as I-MED Pharma’s I-DEFENSE®, is an effective way to protect and moisturize the ocular surface during sleep.
Lagophthalmos (incomplete eyelid closure):
One relatively common ocular disorder that can occur during the night is nocturnal lagophthalmos, which refers to the inability to close the eyelids completely during sleep. There are several potential causes for this condition such as environmental, alcohol consumption, the use of hypnotic medication, and genetic factors, since the disorder can be hereditary. Some people with nocturnal lagophthalmos experience mild or even no symptoms at all, as partially open eyes during sleep can frequently be observed in healthy individuals. Others can experience more severe discomfort and have significant ocular symptoms, which can include dryness, irritation, soreness, foreign body sensation, eye pain, eye watering, and sometimes blurred vision. Often, symptoms are worse in the morning after sleep and improve during the day.
Lagophthalmos can occur during the day as well, when, during blinking, the upper and lower eyelids do not form a complete, closed seal. This ineffective blink leaves part of the eye exposed, causing evaporation of the tear film and leading to the symptoms associated with dry eye disease. While it is the upper eyelids that are mainly responsible for wiping fresh tears across the eyes, a full, complete blink promotes the proper oily secretion from both the upper and lower meibomian glands. Having exposed parts of the eye during the day or night can lead to potential eye damage from dryness and having ineffective or partial blinks can create lower tear production and reduce the quality of the tears.
Additionally, lagophthalmos can be caused by facial nerve palsy (such as Bell’s palsy). Facial palsy, which can result from a variety of causes including infection, genetics, and trauma, involves facial nerve damage, weakness, and paralysis. The ocular consequence to these facial nerve impairments is lagophthalmos, as the nerve damage may result in the eyelid being unable to close completely.
There are several ways to manage and relieve the symptoms associated with lagophthalmos, which can be discussed with your primary eye care provider. A simple measure that can be taken to help reduce the symptoms associated with lagophthalmos can be in rearranging the sleeping environment to minimize direct air flow to the eyes (for example from an air vent or ceiling fan) as well as increasing the humidity in the room. Another step that can be taken for symptom management is by using ophthalmic ointment at night and viscoadaptive artificial tears or eye drops during the day.
The use of nighttime eye ointment (such as I-DEFENSE®) and daytime eye drops is an effective and preventative eye care routine that can improve both daytime and nighttime eye symptoms, which in turn can lead to better daytime comfort as well as better sleep quality.
Floppy Eyelid Syndrome and Obstructive Sleep Apnea:
Floppy eyelid syndrome is characterized by floppy, rubbery eyelids that are easily everted (turned inside out) during sleep. While the exact cause of this syndrome is not known, a suggested cause could be the mechanical stress from rubbing and stretching the eyelid against the pillow or bed while asleep. The symptoms of this syndrome are similar to those in lagophthalmos such as eye watering, discomfort, and blurred vision in the involved eye, and symptoms are worse on waking and improve during the day.
A large majority of people with floppy eyelid syndrome also have obstructive sleep apnea, a condition where the later and deeper stages of sleep are never reached and they are therefore chronically sleep deprived. This is due to repeated episodes of the upper airway narrowing or closing during deeper sleep stages, causing the person to awaken which opens the airways. This cycle is repeated over and over throughout the night. In addition to the association between the two conditions, it appears that floppy eyelid syndrome can be an indicator of severe obstructive sleep apnea.
To manage the ocular symptoms from floppy eyelid syndrome, often resolving the issues associated with obstructive sleep apnea can help, if both conditions are present. Similar to the management of lagophthalmos, keeping the eyes protected and well lubricated at night can help to protect the ocular surface from the associated dry eye symptoms caused by keeping one or both eyes open during sleep.
BENEFITS OF PROTECTING THE EYES AT NIGHT
Dry eye syndrome affects millions of people and is a growing health concern. With the increasing knowledge of sleep related disorders, the awareness of the link between sleep quality and ocular health is also rising. Protect your eyes at night by using I-DEFENSE® hydrating and lubricating dry eye ointment. I-DEFENSE® contains 0.40% sodium hyaluronate and provides maximum relief for severe chronic dry eye through its prolonged contact-time with the ocular surface and formulation. Protecting the eye from nighttime damage can improve both sleep quality as well as daytime eye comfort. Better quality sleep and better daytime ocular relief provides an overall benefit to not only your mood, mental and physical health, but also to your overall quality of life.
Speak with your eye doctor to learn more about how using a nighttime dry eye ointment can benefit you.
 Alan A McNab, “The Eye and Sleep,” Clinical & Experimental Ophthalmology 33, no. 2 (April 2005): 117, https://doi.org/10.1111/j.1442-9071.2005.00969.x.
 McNab, “The Eye and Sleep,” 117.
 Shawn H Tsai et al., “Nocturnal Lagophthalmos,” International Journal of Gerontology 3, no. 2 (2009): 89, https://doi.org/10.1016/S1873-9598(09)70027-4.
 Aya Takahashi et al., “Nocturnal Lagophthalmos and Sleep Quality in Patients with Dry Eye Disease,” Life 10, no. 7 (July 4, 2020): 105, https://doi.org/10.3390/life10070105.
 Tsai, “Nocturnal Lagophthalmos,” 89.
 Mariko Itakura et al., “Topical Rebamipide Improves the Ocular Surface in Mild Lagophthalmos,” Clinical Ophthalmology 7 (2013): 1333, https://doi.org/10.2147/OPTH.S47445.
 Vikesh Patel et al., “Blink Lagophthalmos and Dry Eye Keratopathy in Patients with Non-Facial Palsy: Clinical Features and Management with Upper Eyelid Loading,” Ophthalmology 118, no. 1 (2011): 201, https://doi.org/10.1016/j.ophtha.2010.04.037.
 Joseph W Sowka, “‘Like Sandpaper in the Morning’: Here’s How You Can Help Break the Vicious Cycle of Nocturnal Lagophthalmos,” Review of Optometry 149, no. 4 (April 15, 2012): 75, https://link.gale.com/apps/doc/A289217524/AONE?u=lond95336&sid=AONE&xid=3dde1430.
 Tsai, “Nocturnal Lagophthalmos,” 94.
 E. Andrew Waller, Rick E. Bendel, and Joseph Kaplan, “Sleep Disorders and the Eye,” Mayo Clinic Proceedings 83, no. 11 (2008): 1252-3, https://link.gale.com/apps/doc/A189510074/AONE?u=lond95336&sid=AONE&xid=98bacb9f.
 McNab, “The Eye and Sleep,” 119.
 McNab, “The Eye and Sleep,” 119-120.
 Waller, Bendel, and Kaplan, “Sleep Disorders and the Eye,” 1254.