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Exposure Keratopathy

URGENT — Adnexa

Symptoms

irritation, burning, and foreign body sensation

excessive tearing and redness

symptoms typically worse in the morning

Clinical Findings

Eyelid dysfunction

  • inadequate blink or incomplete closure (lagophthalmos)
  • eyelid deformity, malposition (ectropion), or retraction

Corneal and surface signs

  • hallmark: inferior punctate epithelial erosions (spk)
  • conjunctival injection and chemosis
  • advanced: corneal erosion, stromal infiltrate, ulceration, or thinning

Etiology

Facial nerve (CN VII) palsy

  • bell’s palsy (idiopathic/viral) and ramsay-hunt syndrome (vzv)
  • iatrogenic: post-acoustic neuroma surgery or parotid malignancy infiltration
  • central stroke: typically spares the upper face and is less severe

High-risk "blind-and-numb" cornea

  • combined cn vii palsy and cn v involvement (reduced sensation)
  • poor bell phenomenon (globe fails to rotate upward on closure)
  • high risk of rapid progression to perforation

Orbital and lid causes

  • proptosis: thyroid eye disease (ted) or orbital tumors
  • structural: post-blepharoplasty retraction or floppy eyelid syndrome (osa)

Reduced blink

  • parkinson disease or neurotrophic state
  • icu/sedated patients: loss of blink reflex and lid closure

Red Flags

inferior corneal thinning or ulceration (perforation risk)

combined cn vii palsy, anesthesia (cn v), and poor bell phenomenon

proptotic thyroid eye disease with central exposure

unconscious or ventilated icu patients without lid protection

Investigations

Lid and blink function

  • evaluate gentle closure (simulating sleep) to find nocturnal lagophthalmos
  • assess bell phenomenon (upward rotation on forced closure)
  • check lid laxity (snap-back/distraction tests for floppy eyelid)

Corneal integrity

  • fluorescein staining: check for hallmark inferior spk or epithelial defects
  • corneal sensation: test before anesthesia to assess cn v status

Systemic workup

  • investigate cn vii palsy source (mri for cpa tumor or parotid exam)
  • thyroid function tests and orbital imaging if proptosis is present
  • sleep study if floppy eyelid/osa suspected

Treatment

Medical management

  • intensive pf artificial tears (q1–2h) and lubricating ointment (qhs to q2h)
  • nocturnal protection: eyelid taping, moisture-chamber goggles, or patching
  • in-office amniotic membrane (prokera) for non-healing defects

Surgical intervention

  • tarsorrhaphy: partial or temporary sewing/gluing of lids
  • gold or platinum weight implants: for permanent cn vii palsy
  • lid reconstruction: for ectropion or cicatricial retraction
  • orbital decompression: for severe thyroid-related proptosis

Infection control

  • broad-spectrum topical antibiotics if an infiltrate or ulcer develops

Clinical Pearl

if the eyelids do not meet during a forced blink, the cornea will dry out regardless of how many drops you prescribe — lateral tarsorrhaphy or lid weight is the definitive fix for chronic exposure.

Differential Diagnosis

  • neurotrophic keratopathy
  • dry eye syndrome
  • contact lens-related keratopathy
  • topical medication toxicity (medicamentosa)

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