Other options include instillation of gels or ointments before bed, but these don’t create a long enough seal to prevent NES. Sleep masks don’t address the cause-inadequate light seal-but they may provide a brief moisture chamber if the patient is able to maintain them throughout the night. Other than surgery, there’s sleep masks, but they only work for select patients. For that reason, a treatment that addresses the lids would be ideal however, until now, these options were limited. If you are trying to treat a patient’s ocular surface disease but not managing their ILS, there is an uphill battle to climb, as you’re often treating the resulting inflammation, corneal staining or desiccation, MGD and blepharitis without treating the cause. SleepTite, a daily disposable lid seal, is a single-use, hypoallergenic device that holds the eye closed to prevent NES due to inadequate lid closure. If the lids return to their normal position slowly, the patient has poor lid performance, putting them at greater risk of having problems at night. To test elasticity, simply pull down the patient’s lower lid and let it snap back into place. 7 It is also useful to ask the patient to squeeze their eyes shut to determine whether complete closure is even possible.Īnother useful test is the lid snap. In fact, research shows that nocturnal lid seal insufficiency is associated with desiccating stress and greater symptom severity. The more light that leaks, the worse the seal and the greater the exposure. As you direct the light toward the interpalpebral fissure, look for light leakage along the lid and between the lashes. 6 Simply darken the room and place a transilluminator against the patient’s closed outer upper eyelids. This test helps you determine whether a patient’s seemingly closed eyelids are actually protecting the ocular surface and preventing evaporation during sleep. The Korb-Blackie light test is probably the most simple and straightforward way to detect ILS if you feel the need for a confirmatory test beyond morning symptoms. Conversely, if the patient indicates their eyes feel particularly bad upon waking, ILS is the likely diagnosis. If they say their eyes feel fine in the morning but get worse throughout the day, we can usually rule it out. This can be as easy as asking patients how their eyes feel when they first wake up. Click image to enlarge.ĭespite our busy schedules and heavy patient loads, investigating NES in new dry eye patients as well as refractory cases is time well spent. The Korb-Blackie light test can detect ILS by determining if the patient’s closed lids are protecting the ocular surface and preventing evaporation during sleep. Newer research indicates that even in the majority of patients who show no apparent lid abnormalities, insufficient lid seal is present and leads to nighttime dryness. A fan in the bedroom, CPAP devices or forced air heat can make symptoms worse. Environmental factors likewise should be considered. In addition, patients with NES often have another condition, such as meibomian gland dysfunction (MGD), that contribute to the disease. These include floppy eyelid syndrome, surgical cosmetic procedures and injections, lid deformities, age-related lid laxity, dermatochalasis, senile ectropion and Graves’ disease. Several factors contribute to the development of NES, many of which are directly linked to inadequate lid seal (ILS). 3 However, many patients’ lids don’t adequately close at night. 2 Closed lids protect the eye from desiccation. Our eyes don’t produce as many tears while we’re sleeping, which automatically puts patients in a dry eye state during sleep. This form is far less obvious, as this under-identified and under-treated condition is caused by nocturnal evaporative stress (NES) and is highly prevalent in refractory dry eye. If you have a patient whose dry eye is not improving despite treatment, it’s time to consider inadequate eyelid closure, sometimes referred to as nocturnal lagophthalmos. Consider that 61% of symptomatic dry eye patients across the spectrum of disease severity have compromised lid closure. But in fact, the greater culprit may be lurking in a patient’s nighttime environment. We o ften think about our dry eye patients’ daytime experiences and how these may exacerbate their symptoms.
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