Gold in the balance: How does patient posture affect eyelid closure?

A retrospective audit was conducted of four patients with upper eyelid gold weights (inserted >5 years ago) as treatment for facial nerve palsy-related lagophthalmos. Each patient was presently examined for lagophthalmos ("opened" or "closed") at three different patient inclinations (lying flat at 0º, lying back at 45º, and sitting upright at 90º). In all four cases at 0º inclination, the upper eyelid remained "open" with significant lagophthalmos, and therefore the ocular surface was vulnerable. At other inclinations, 45º and 90º, the eyes were substantially "closed" and the ocular surface was protected. We discuss the mechanism by which this occurs. We suggest that patients fitted with upper eyelid gold weight implant who do not show adequate closure during postoperative clinical examination or signs of corneal show should try sleeping in a slightly upright position to aid ocular surface protection.