When corneal sensation is normal, the symptoms of exposure keratopathy are similar to those associated with dry eye, including foreign-body sensation and photophobia. Exposure keratopathy is characterized by punctate epithelial erosions that usually involve the inferior one-third of the cornea; however, the entire corneal surface can be involved in severe cases. Large, coalescent epithelial defects may result, which may in turn lead to infectious or sterile ulceration and perforation. The risk of a stromal melt is greater when exposure is associated with a neurotrophic or anesthetic cornea (see the section Neurotrophic Keratopathy and Persistent Corneal Epithelial Defects).
Therapy is similar to that for severe evaporative dry eye. In the earliest stages, nonpreserved artificial tears instilled during the day and ointment applied at bedtime may suffice. Taping the eyelid shut at bedtime can help if the exposure occurs mainly during sleep. Bandage contact lenses should be used with caution in patients with exposure keratopathy because of the risk of desiccation and infection. For cases in which the problem is likely to be temporary or self-limited, temporary tarsorrhaphy using tissue adhesive or sutures may be helpful. However, if the problem is likely to be long-standing, definitive surgical therapy to correct the exposure is recommended.
Most commonly, surgical management consists of permanent lateral and/or medial tarsorrhaphy (see Chapter 13). Insertion of gold or platinum weights into the upper eyelid is also an effective, more cosmetic approach to promote eyelid closure. Reported complications of gold weight implants include infection, implant malposition, extrusion, induced astigmatism, unacceptable ptosis, and noninfectious inflammatory response to the gold. The weights remain stable during magnetic resonance imaging. In addition, correction of any associated eyelid abnormalities, such as ectropion, entropion, and/or trichiasis, is indicated. For example, in cases of paralytic ectropion of the lower eyelid, a horizontal tightening procedure may also be beneficial.
See BCSC Section 7, Oculofacial Plastic and Orbital Surgery, for further discussion of thyroid eye disease, lagophthalmos, and proptosis.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.