Q: I have a contact lens patient who awakens every morning with one eyelid completely shut and can’t open her eye for several minutes, although she can lift the eyelid freely. Her palpebral conjunctiva is clear, and her cornea doesn’t seem violated. Is this related to her lens wear?
A: It’s possible that this could be apraxia of eyelid opening, a typically benign condition that basically is a problem with the eye’s neural circuitry. It’s considered a type of dystonia—involuntary muscle movement or spasms. The identifying feature is the inability of the levator muscle to raise the upper lid. Frequently, it is associated with Parkinson disease and other diseases of the central nervous system.1,2
However, “isolated apraxia of lid opening (not associated with blepharospasm) is extremely rare and I have never seen a unilateral case,” says Richard L. Anderson, M.D., medical director of the Center for Facial Appearances in Salt Lake City. While unilateral apraxia of lid opening is very rare, there have been reported cases.3
Patients more commonly present with blepharospasm rather than apraxia of lid opening. They usually have spasms closing the eyelids and cannot open their eyelids for seconds after the spasm stops. In such cases, if the contraction in the orbicularis muscle is not relieved, the levator cannot fully function.
Botulinum A toxin typically is the first choice for controlling the spasms of the eyelid. “Once you’ve administered the injections, if you try to peel the eyelids open with your fingers and they open easily, then you know you have apraxia,” says Leonid Skorin, Jr., O.D., D.O., staff ophthalmologist at Mayo Clinic Health System, in Albert Lea, Minn. “If you try to open them up and they are still in spasm, then you haven’t treated the blepharospasm sufficiently.”
This patient with presumed apraxia of lid opening tries to use her forehead muscles to raise her eyelids. Photo: Leonid Skorin, Jr., O.D., D.O.
If botulinum A toxin doesn’t provide adequate relief of blepharospasm, or if the patient has functional or cosmetic deformities of the eyelids that prevent an optimal result, Dr. Anderson recommends a myectomy surgery to remove the orbicularis oculi muscle. However, neither of these treatments will help if the patient has isolated apraxia, which sometimes requires surgery to tighten the levator muscle.
Both doctors recommend getting additional information from the patient, as her symptoms could be indicative of a number of conditions.
Other Possibilities
“I would continue to look for a cause of irritation of the affected eye,” Dr. Anderson says. “Ask her to discontinue her contact lens wear, and use a lubricant at bedtime to see if this relieves the condition.”
Ask the patient what type of contact lenses she’s wearing because rigid lenses can have a numbing effect on the eye, interfering with lid function.
“With time, contact lenses can cause some droopiness of the eyelids, especially the rigid lenses,” Dr. Skorin says. “If she’s been wearing them for decades, she could have pulled the eyelid so frequently to insert and remove the lenses that it’s loosened up the levator muscle.”
Thyroid gland disease could be another possibility, especially because it’s more common in females. People with thyroid gland disease commonly have eye difficulties, which usually is caused by abnormal swelling of the soft tissue around the eyes and by enlargement of the muscles that move the eyes and open the eyelids.
1. Wills Eye Hospital. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Philadelphia, Pa: Lippincott; 2008.
2. Ugarte M. Apraxia of Lid Opening. Available at:
http://emedicine.medscape.com/article/1214008-overview. (Accessed November 2, 2011).
3. Cherian V, Foroozan R. Benign unilateral apraxia of eyelid opening. Ophthalmology. 2010 Jun;117(6):1265-8. Epub 2010 Feb 16.
