What is the workup for inability to close one eyelid (lagophthalmos)?

Workup for Unilateral Lagophthalmos (Inability to Close One Eyelid)

Initial Clinical Assessment

Begin by determining the underlying etiology through focused history and examination, as the cause dictates both urgency and management approach. 1, 2

History Elements to Elicit

• Onset and duration: Acute onset (hours to days) suggests Bell's palsy or stroke, while gradual onset may indicate tumor, chronic nerve compression, or thyroid eye disease 1, 2
• Associated symptoms: Facial weakness, taste changes, hyperacusis, or ear pain point toward facial nerve pathology 1
• Recent trauma or surgery: Particularly dacryocystorhinostomy, facial surgery, or parotid procedures 3
• Ocular symptoms: Burning, itching, eye irritation, vision changes, or pain indicate corneal exposure complications 1
• Systemic conditions: Diabetes, thyroid disease, Lyme disease exposure, or immunocompromise 1

Physical Examination Components

Assess facial nerve function systematically across all branches, not just the orbicularis oculi: 1

• Degree of paralysis: Complete versus incomplete facial paralysis (this determines whether electrodiagnostic testing is needed) 1
• Lagophthalmos measurement: Measure the gap between upper and lower lid margins in millimeters during gentle closure, forced closure, and spontaneous blink 1, 2
• Bell's phenomenon: Check if the eye rolls upward with attempted closure (protective mechanism) 2
• Other facial nerve branches: Forehead wrinkling, eyebrow elevation, nasolabial fold symmetry, smile symmetry, lower lip depression 1

Ophthalmologic Evaluation

All patients with lagophthalmos require detailed ocular surface assessment to prevent vision-threatening complications: 1, 4

Essential Ophthalmic Tests

• Slit-lamp biomicroscopy: Document corneal epithelial defects, punctate staining with fluorescein, corneal edema, infiltrates, ulcers, or scars 1, 4
• Tear film assessment: Schirmer test to quantify tear production (critical for determining medical necessity of interventions) 1, 4
• Corneal sensation testing: Reduced sensation increases exposure keratopathy risk 2
• Visual acuity: Baseline documentation 1
• Photographic documentation: Standardized photos showing lid position and lagophthalmos severity 4

The frequency of ophthalmic follow-up should range from monthly in severe cases to once or twice yearly in mild cases. 1

Electrodiagnostic Testing Decision

Do NOT perform electrodiagnostic testing (electromyography or electroneuronography) in patients with incomplete facial paralysis, as it provides no benefit and does not change management. 1

Electrodiagnostic testing is only considered in complete facial paralysis to assess prognosis and guide surgical timing, but this is not standard practice per current guidelines. 1

Etiologic Workup Based on Clinical Presentation

For Acute Unilateral Facial Palsy (Bell's Palsy Pattern)

• Clinical diagnosis is sufficient if presentation is typical (acute onset, unilateral, no other neurologic signs) 1
• MRI with gadolinium is indicated only if: atypical features present, gradual onset, recurrent episodes, or failure to improve within 3-4 weeks 1
• Lyme serology if endemic area exposure 1
• Blood glucose/HbA1c if diabetic risk factors present 1

For Lagophthalmos with Proptosis

• Thyroid function tests (TSH, free T4, T3) and thyroid antibodies (TSI, anti-TPO) 2
• Orbital imaging (CT or MRI) to assess for masses, orbital inflammation, or thyroid eye disease 2

For Post-Surgical or Post-Traumatic Cases

• Review surgical records to identify nerve injury risk 3
• Imaging only if concern for bony injury or hematoma 2

For Congenital or Chronic Progressive Cases

• Detailed examination for syndromic features (urofacial syndrome, congenital fibrosis syndromes) 5, 6
• Genetic consultation if syndromic features present 5

Immediate Protective Measures During Workup

While completing the diagnostic workup, immediately implement eye protection to prevent corneal complications—this is a strong recommendation regardless of etiology: 1

• Preservative-free lubricating drops: Carboxymethylcellulose 0.5-1%, carmellose sodium, or hyaluronic acid every 1-4 hours while awake 1
• Ophthalmic ointment: Petrolatum-based ointment at bedtime (more effective moisture retention but causes vision blur) 1
• Nighttime eye taping or moisture chamber: Particularly critical for nocturnal lagophthalmos 1
• Sunglasses: Outdoor protection from wind and debris 1

Common pitfall: Improper eye taping technique can cause corneal abrasion. Ensure patients are carefully instructed: tape should pull the lower lid upward and the upper lid downward to achieve complete closure without pressure on the globe. 1

Red Flags Requiring Urgent Ophthalmology Referral

• Corneal epithelial defects or ulceration on fluorescein staining 1, 4
• Vision changes or severe pain 1
• Severe lagophthalmos (>5mm gap) with poor Bell's phenomenon 2
• Failure of conservative eye protection within days to weeks 1

Documentation for Potential Surgical Intervention

If lagophthalmos persists beyond 3-6 months or conservative measures fail, document the following for medical necessity determination of procedures like gold weight implantation or tarsorrhaphy: 4

• Serial photographs showing lagophthalmos severity 4
• Corneal examination findings with fluorescein staining results 4
• Schirmer test values demonstrating inadequate lacrimation 4
• Failed conservative treatments with specific frequency and duration documented 4