What is the treatment for eyes that are shut closed?

Treatment for Eyes That Are Shut Closed

For eyes that are shut closed, implement immediate eye protection measures including lubricating ophthalmic drops, ointments, and moisture chambers to prevent corneal damage and preserve vision. 1

Causes of Eyes Shut Closed

The treatment approach depends on the underlying cause:

1. Acute Angle Closure Crisis (AACC)

   • Presents with sudden eye closure, pain, blurred vision, and high intraocular pressure
   • Requires emergency intervention to prevent permanent vision loss

2. Bell's Palsy

   • Causes incomplete eye closure (lagophthalmos) due to facial nerve paralysis
   • Risk of corneal exposure and damage

3. Myasthenia Gravis

   • Variable ptosis and strabismus that worsen with fatigue
   • May improve temporarily with rest or ice pack test

Treatment Algorithm

Step 1: Immediate Management for Eye Protection

• Lubricating ophthalmic drops: Frequent administration to hydrate and protect cornea 1
• Ophthalmic ointments: More effective for moisture retention but may blur vision 1
• Moisture chambers: Using polyethylene covers, particularly effective at night 1
• Eye patching or taping: Ensure proper patient education on technique 1

Step 2: Treat Underlying Cause

For Acute Angle Closure Crisis:

1. Medical therapy to reduce IOP:

   • Topical beta-adrenergic antagonists
   • Topical alpha2-adrenergic agonists
   • Topical, oral, or intravenous carbonic anhydrase inhibitors
   • Topical miotics
   • Oral or intravenous hyperosmotic agents 1

2. Definitive treatment:

   • Laser iridotomy is the preferred surgical treatment due to favorable risk-benefit ratio 1
   • If laser iridotomy not possible, consider paracentesis or incisional iridectomy 1
   • Early lens extraction may be considered in cases with high risk of uncontrollable IOP 1

For Bell's Palsy:

1. Eye protection measures as described in Step 1
2. For severe cases:
   • Detailed ophthalmologic evaluation
   • Consider botulinum toxin injections (temporary improvement)
   • Consider tarsorrhaphy (temporary or permanent)
   • Consider surgery to weight the upper eyelid 1

For Myasthenia Gravis:

1. First-line treatment: Pyridostigmine bromide orally 2-4 times daily (though about half of patients with strabismus-associated myasthenia show minimal response) 1
2. Second-line treatment: Corticosteroids (66-85% of patients show positive response) 1
3. Additional options: Immunosuppressive therapy with azathioprine or newer agents like efgartigimod alfa-fcab 1

Special Considerations

For Acute Angle Closure:

• Evaluate the fellow eye promptly, as it is at high risk for similar event
• Consider prophylactic laser peripheral iridotomy for the fellow eye 1
• Clear lens extraction may be superior to laser peripheral iridotomy for IOP control in primary angle closure with elevated IOP 1

For Bell's Palsy:

• Monitor for symptoms such as burning, itching, eye irritation, changes in vision, and pain 1
• Ensure proper patient education on eye protection techniques
• Consider combination of different eye protection methods for optimal results 1

For Myasthenia Gravis:

• Perform diagnostic tests including ice pack test, rest test, and possibly single-fiber electromyography 1
• Monitor for development of generalized myasthenia gravis (occurs in 50-80% of patients with initial ocular symptoms) 1

Follow-up and Monitoring

• Regular follow-up to assess corneal integrity
• Monitor intraocular pressure in cases of angle closure
• Assess for improvement in underlying condition
• Adjust treatment regimen based on response

Pitfalls and Caveats

1. Delayed treatment: Can lead to permanent corneal damage and vision loss
2. Improper eye taping/patching: Ensure proper patient education to avoid corneal damage
3. Missing systemic disease: Always consider that ocular symptoms may be part of a systemic condition
4. Inadequate lubrication: Insufficient frequency of drops or ointments can lead to exposure keratopathy
5. Failure to address underlying cause: Symptomatic treatment alone is insufficient

Early intervention with appropriate eye protection measures is critical to prevent corneal damage while addressing the underlying cause of eye closure.