Mermerkaya et al reported nocturnal lagophthalmos in 12 of 15 children with urofacial syndrome. 1 An interesting association has been found between nocturnal lagophthalmos and urofacial syndrome, which is characterized by a paradoxic inversion of the corners of the mouth when laughing giving the impression of crying and frequent severe urinary infections. However, most cases are of unknown etiology. 6Ĭlinically, lagophthalmos can be seen in patients with anatomic conditions that make it functionally harder to close the eyelid completely (eg, proptosis) or anatomic deficiencies surrounding eyelid (eg, palpebral insufficiency), heavy alcohol ingestion, and use of sedative hypnotics. The inability to fully close the eyelid leads to corneal exposure, dryness of the eye, keratitis, and/or corneal abrasion. 5 Closure of the eyelid is necessary for tear distribution across the eye during sleep. In 1936, Hall examined 234 patients during sleep and concluded that the eyes could be found in different positions. In 1923, Sir Charles Bell postulated that during sleep, the eye rolled upward to protect the cornea. 4Īlthough eyes move in all directions during sleep, it is routinely accepted that with eyelid closure, the eyes move up and out (lateral). 3 In 1967, Mueller published an observational study of children of the Amharic descent, who slept with their eyes open. A single polysomnography case report in a 5-year-old girl with nocturnal lagophthalmos showed eye movements during non-rapid eye movement sleep. 2 Prevalence and clinical characteristics about this disorder remain unknown in children. In this cohort, all participants reported foreign body sensations in their eyes, but only 17% had eye redness. 1 In a cohort of 42 adults with nocturnal lagophthalmos, 57% were women and 84% had unilateral lagophthalmos. Five percent of adults are estimated to sleep with their eyes open, making the condition relatively common. Incomplete closure of the eyelids during sleep, called nocturnal lagophthalmos, has been rarely reported in the medical literature, with little known about the epidemiology or clinical characteristics of this disorder. The patient was recorded having her eyes open during electroencephalographic rapid eye movement ( Figure 1) and non-rapid eye movement sleep ( Figure 2) see also Video 1 and Video 2 in the supplemental material. The respiratory parameters showed an obstructive apnea-hypopnea index of 1 event/h without significant central apneas or hypoventilation, and a nadir oxygen saturation of 94.7%. The percent of time spent in each sleep stage was: N1 4.5%, N2 43.4%, N3 34.5%, and R 17.6%. The following results were reported: total sleep time of 522 minutes, sleep latency of 8.3 minutes, sleep efficiency of 95.9%, and an arousal index of 7 events/h. The patient had a normal physical examination for age, including typical symmetric facial structure, normal eye and eyelid examination, and size 1+ tonsils.Ī sleep study was obtained to evaluate for obstructive sleep apnea given history of snoring. Extended family history was notable for severe sleep apnea in a grandparent and an aunt, but negative for nocturnal lagophthalmos or other ophthalmologic disorders. The patient otherwise was in good health with appropriate development, with no significant past medical or surgical history. Once awake, she denied daytime sleepiness. The patient reportedly awoke routinely at 8:00 am appearing refreshed. Once asleep, the patient’s parents reported snoring and mouth breathing, but denied witnessed apneas, restless sleep, restless legs, leg kicking, nightmares, night terrors, or sleepwalking. The patient was then observed to behaviorally fall asleep, but her eyes failed to close. As parents were unsure if she was awake or asleep, the patient was given melatonin 3 mg to ensure sleep. Parents reported that during routine checks after she had fallen asleep, they noticed that the patient’s eyes appeared open despite appearing to be asleep. Recommendations included an eye lubricant and a full sleep evaluation.Ī pediatric sleep evaluation revealed that the patient had a routine bedtime of 9:00 pm and fell asleep on her own in her own bed and in her own room. A 7-year-old girl is referred for sleep evaluation because of parental concern of “sleeping with her eyes open.” She was referred by an ophthalmologist, who had been consulted for the patient’s complaints of dry eyes in the morning.
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