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Some people have eyes that burn and hurt especially in the morning, as soon as they wake up, and improve during the day. One possible reason is that the eyelids do not close completely during sleep. On this page we explain what causes this, how the condition is recognised, which measures help and when surgery needs to be considered.
What happens when the eyelids do not close
During sleep the eyelids should close completely and protect the cornea (the clear window at the front of the eye) from drying out. When a small gap remains, even of just a few millimetres, part of the cornea stays exposed to the air for hours. This condition is called nocturnal lagophthalmos (incomplete closure of the eyelids during sleep).
The exposure damages the top layer of cells of the cornea, usually in a band across its lower part. This damage is called exposure keratopathy. In most cases it causes discomfort and slightly blurred vision in the morning. In severe cases, without treatment, the cornea can develop a wound and even become infected.
Why it happens
- Facial nerve palsy: this nerve works the muscle that closes the eyelids. Bell's palsy (a sudden paralysis of one side of the face) is the best-known cause, but a stroke, surgery in the area of the ear or tumours can also damage the nerve.
- After eyelid surgery: surgery to lift the eyelids or remove excess skin can, in some people, shorten the eyelid slightly, so that it does not close completely. This usually improves with time, but not always.
- Thyroid eye disease: swelling of the tissues behind the eye pushes it forward, and the eyelids are pulled back. The eye stays more exposed by day and at night. More on this on the dry eye and the thyroid gland page.
- Naturally prominent eyes: in some people the structure of the face and the eye socket makes the eye more prominent, and the eyelids have difficulty covering it completely during sleep.
- A leaking CPAP mask: people who sleep with a machine for sleep apnoea can suffer from a stream of air leaking from the mask straight into the eyes. Even without lagophthalmos, such a stream dries the eye.
- Age and loosening of the eyelids: with age the eyelids become looser, and sometimes they do not sit snugly against the eye.
The symptoms: why especially in the morning
The main sign is dryness, burning, pain or a gritty, sandy feeling that is especially strong in the morning and improves after a few hours of blinking. Some people wake up with a red eye, with blurred vision that gradually clears, or with a feeling that the eyelid is "stuck" to the eye. Sometimes the problem is in one eye only, for example after Bell's palsy. Partners sometimes say that they see a white strip between the eyelids during sleep.
Why it is not always recognised
Mild nocturnal lagophthalmos is not rare, and many people do not know they have it. People who have it usually describe ordinary "dry eye", and are given lubricating drops that help during the day but do not solve the morning burning. Even at a routine examination, when the patient sits awake in front of the doctor, the eyelids close well when blinking, and the problem can be missed if gentle closure is not specifically checked.
So if dryness treatment is not helping, and the symptoms are strongest in the morning, it is worth telling the doctor so explicitly. That detail alone points the examination in the right direction. It is also worth mentioning if the dryness is stronger in one eye, because this may point to a local cause such as weakness of the facial nerve or previous surgery.
How it is diagnosed
The eye doctor asks about the symptoms and their timing, about previous operations, about conditions such as thyroid disease and about CPAP use. Then they check:
- Eyelid closure: you are asked to close your eyes gently, as in sleep, and the doctor checks whether a gap remains and how big it is. The strength of closure and the upward movement of the eye while the eyes are closed are also checked.
- Fluorescein staining (a harmless yellow-orange dye) and examination with a slit lamp (a microscope for examining the eye), which show the damage to the cornea and where it is.
- Other dry eye tests, because there is often also a shortage of tears or blockage of the meibomian glands at the same time, and treatment needs to address all the components.
Details of the tests are on the dry eye testing page. When the cause is not clear, for example new weakness in the face, further assessment by another doctor may be needed.
The standard measures
Treatment is tailored to the cause and the severity. In mild to moderate cases, simple measures usually come first:
- An ointment or thick gel before sleep: these form a protective layer over the cornea during the night. The ointment blurs vision, so it is put in just before sleep.
- Lubricating drops during the day, preferably preservative-free when you use them often. See preservative-free drops.
- Moisture goggles or sleep eye shields: sealed shields that create a moist environment around the eye and prevent air flow. Some people prefer them to taping.
- Eyelid taping, only on a doctor's instructions and using the method they demonstrate.
- Treating the cause: refitting the CPAP mask, getting thyroid disease under control, and following recovery from Bell's palsy.
When home measures are not enough
If the morning dryness continues, or the examination shows damage to the cornea despite treatment, an examination by an eye doctor who specialises in dry eye helps to find out what else is contributing to the problem. At the clinic the following can be combined, as needed and after an examination:
- Dry eye testing: to find out whether there is also a shortage of tears or a problem with the glands, and to follow the condition of the cornea over time.
- Punctal plugs: when there is also a shortage of tears, they may keep more moisture on the eye. They do not solve the closure problem itself.
- Bandage contact lens: in selected cases, for example when there is a corneal defect that is struggling to heal, and under close follow-up. When the eye is very exposed the lens can dry out, so it is not always suitable.
When surgery is considered
When closure remains inadequate over time and the cornea is damaged despite conservative measures, or when it is clear that the problem will not improve by itself, surgery is considered. The surgery is done by an oculoplastic surgeon (an eye doctor who specialises in surgery of the eyelids and the eye socket), and is not offered at the clinic. There are several types of surgery, for example adding a tiny weight to the upper eyelid to help it close, tightening the lower eyelid, or partially stitching the eyelids together. The choice depends on the cause and on the examination. Even after surgery, treatment of the eye surface and follow-up remain an important part of the plan.
When to see a doctor straight away: severe eye pain, a drop in vision, a red eye with strong sensitivity to light, a white spot on the cornea or a pus-like discharge. Also seek help at once if you suddenly develop weakness on one side of the face, a drooping corner of the mouth or difficulty closing an eye, because these can be signs of a stroke and need an urgent visit to the emergency department.
Frequently asked questions
How can I tell if my eyes do not close during sleep?
It is hard to tell by yourself, because it happens while you are asleep. Your partner may notice a white strip visible between the eyelids. Another clue is dryness and burning that are especially strong as soon as you wake up and improve during the day. The eye doctor can check how your eyelids close and look for signs of exposure on the cornea.
Is it all right to tape my eyelids shut at night?
Eyelid taping is done only on a doctor's instructions, with the type of tape and method they explain. Taping done incorrectly can actually cause the eyelid to open and scratch the cornea.
I use a CPAP machine and wake up with dry eyes. What can I do?
Often air leaks from the mask towards the eyes. It is worth contacting whoever fits your machine to check the mask size and fit. Do not stop CPAP treatment without advice, and at the same time see an eye doctor if the dryness continues.
Does the clinic perform eyelid surgery?
No. When surgery is needed, the referral is to an oculoplastic surgeon (an eye doctor who specialises in eyelid surgery). The clinic deals with examination, treatment of the eye surface and follow-up.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.
- Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511-538.
- Gupta A, Sadeghi PB, Akpek EK. Occult thyroid eye disease in patients presenting with dry eye symptoms. Am J Ophthalmol. 2009;147(5):919-923.
- Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.