Eyelid Not Closing (Facial Paralysis)

Lagophthalmos is nearly always a consequence of damage to the facial nerve (seventh cranial nerve) at some point along its path from the brain to the eyelid muscles. The cause determines whether the paralysis is temporary or permanent, and guides the overall treatment plan.

• Bell's Palsy: The most common cause of acute facial nerve paralysis. Bell's palsy is an idiopathic (of unknown origin) inflammatory condition that causes sudden one-sided facial weakness, including failure of eyelid closure. Most patients recover fully, but during the acute phase corneal protection is essential.
• Facial Nerve Injury from Surgery: Operations on or near the facial nerve — including surgery for acoustic neuroma (vestibular schwannoma), parotid gland tumours, and mastoid surgery — carry a risk of nerve damage. Lagophthalmos following such procedures may be temporary or permanent depending on whether the nerve was preserved or sacrificed.
• Ramsay Hunt Syndrome: Reactivation of the varicella-zoster virus (the chickenpox virus) in the facial nerve ganglion causes ear pain, a blistering rash, and facial paralysis, often with more severe and longer-lasting effects than Bell's palsy.
• Trauma: Fractures of the skull base, lacerations of the face, or blunt injury to the parotid region can disrupt the facial nerve and cause acute lagophthalmos.
• Stroke and Neurological Disease: Central facial nerve palsy from stroke, brain tumours, or demyelinating disease can affect eyelid closure, though this is less common than peripheral (lower motor neuron) causes.
• Infection and Inflammation: Lyme disease, otitis media with facial nerve involvement, and sarcoidosis are less common but recognised causes of facial nerve palsy and secondary lagophthalmos.

Home measures are an essential part of corneal protection while the underlying cause is being treated or while awaiting surgical intervention. They do not treat the nerve itself, but they can prevent irreversible corneal damage during this vulnerable period.

• Frequent Lubricating Eye Drops: Preservative-free artificial tears applied every one to two hours during the day help keep the corneal surface moist and reduce friction. This is the single most important immediate measure.
• Lubricating Eye Ointment at Night: Because the eyelid cannot close during sleep, the cornea is at greatest risk overnight. A thick lubricating ointment (such as simple eye ointment) applied at bedtime provides a prolonged protective film.
• Taping the Eyelid Shut at Night: Medical-grade micropore tape applied horizontally across the closed eyelid at bedtime is a simple and effective way to keep the eye shut during sleep. The tape should be applied gently without stretching the eyelid skin.
• Moisture Chamber Glasses: Spectacles fitted with side shields or moisture chambers around the lenses reduce evaporation and protect the eye from wind and air conditioning — particularly useful for patients who spend time outdoors or in air-conditioned environments.
• Avoid Rubbing the Eye: The cornea of an eye with lagophthalmos is fragile. Rubbing can cause or worsen corneal erosions. Any worsening of pain, redness, or blurred vision should be reported promptly to the treating eye specialist.

Treatment is directed at two goals: protecting the cornea from exposure damage, and restoring or compensating for eyelid closure. The urgency of surgical intervention depends on the degree of corneal exposure and the likelihood of natural nerve recovery.

Non-Surgical Corneal Protection

• Preservative-Free Lubricants: High-viscosity artificial tears and gels used frequently during the day, combined with lubricating ointment at night, form the foundation of corneal protection for all patients with lagophthalmos.
• Scleral Contact Lenses: Large-diameter rigid contact lenses that vault over the cornea and rest on the white of the eye create a fluid-filled chamber in front of the cornea. They provide excellent protection in severe exposure keratopathy and are an option for patients who cannot tolerate surgery.
• Botulinum Toxin Injection into the Levator Muscle: An injection of botulinum toxin into the muscle that opens the upper eyelid causes a temporary, induced ptosis (drooping) that holds the eyelid down and protects the cornea. This is a temporary measure (lasting 8–12 weeks) used while waiting for nerve recovery or until surgical correction is planned.

Surgical Treatment

• Gold Weight Eyelid Implant: The most widely used surgical treatment for lagophthalmos from facial nerve palsy. A small, precisely weighted gold or platinum implant is placed beneath the skin of the upper eyelid, over the tarsal plate. Gravity causes the implant to assist passive eyelid closure during blinking and sleep, while the levator muscle can still open the eye normally. The implant is reversible and can be removed if facial nerve function recovers.
• Lower Eyelid Tightening: Facial nerve palsy often also causes the lower eyelid to fall away from the eye (ectropion), widening the gap between the lids. Tightening the lower eyelid reduces the exposed corneal surface area and is frequently combined with gold weight implantation.
• Tarsorrhaphy: Partial or complete surgical joining of the upper and lower eyelids at the outer corner (lateral tarsorrhaphy) narrows the eyelid opening and reduces corneal exposure. It is particularly useful in patients with severe exposure keratopathy where immediate protection is needed, or where other procedures are not possible. It does alter the appearance of the eye.

Managing facial nerve palsy is often a long-term process. These habits help protect the eye and support overall recovery throughout the treatment journey.

• Never Skip Lubricating Drops: Even when the eye feels comfortable, the cornea may be drying unnoticed. Regular lubrication — at least every two hours — must become a consistent habit for as long as eyelid closure is impaired.
• Seek Urgent Help for Eye Pain or Vision Changes: Corneal ulceration is a medical emergency. Any sudden increase in eye pain, marked redness, discharge, or blurred vision should be assessed by an eye specialist the same day.
• Protect the Eye from the Environment: Wind, dust, and air conditioning all accelerate corneal drying. Wrap-around glasses or side-shielded frames help outdoors; a humidifier indoors can reduce evaporative tear loss.
• Attend Regular Follow-up Appointments: Regular slit-lamp examinations allow the oculoplastic surgeon or corneal specialist to detect early signs of exposure keratopathy before they progress to corneal scarring or ulceration.
• Discuss Facial Physiotherapy: In patients with Bell's palsy or post-surgical facial nerve palsy, facial physiotherapy and neuromuscular retraining can support nerve recovery and help restore voluntary muscle function, including the orbicularis oculi.
• Plan for the Long Term: If nerve recovery does not occur within 6–12 months, permanent surgical correction (gold weight implant) is usually recommended to provide reliable, long-term corneal protection. Discuss the timing and options with your oculoplastic surgeon.