How facial palsy affects the eye
The facial nerve (the seventh cranial nerve) controls the muscles of facial expression, including the orbicularis muscle that closes the eyelids. When it stops working, one side of the face weakens, and the eye on that side may not close or blink fully. Incomplete eyelid closure is called lagophthalmos, and facial nerve paralysis is its main cause.[2]
Without a full blink, the tear film evaporates and the cornea (the clear front window of the eye) dries out. That can progress to exposure keratopathy, corneal ulcers, and even perforation.[2] Facial palsy can also cause a lower lid that sags away from the eye (ectropion), abnormal linked movements of the face (synkinesis), and watering when eating.[3] The way the cornea breaks down is covered on our exposure keratopathy page, so this page focuses on facial palsy itself.
Bell’s palsy is the most common cause, accounting for 38% to 83% of cases of facial weakness. Over 80% of people with Bell’s palsy recover on their own, and 90% to 97% improve with timely medical treatment.[1] A natural reflex called Bell’s phenomenon rolls the eyes upward when the lids close, which helps protect the cornea and matters especially when the lids can’t close fully.[1]
Other causes include trauma, surgery, tumors, stroke, and conditions present from birth.[6] Surgery for acoustic neuroma, a tumor near the hearing nerve, is a well-known cause, and it can also damage the nerve that gives the cornea its feeling. A cornea that is both exposed and numb is at particular risk.[5]
The approach depends on the cause. In acute Bell’s palsy, steroids with or without antiviral medicine are often effective. Long-lasting or permanent paralysis calls for protecting the eye over the long term.[10]
How a scleral lens helps when the lids can’t close
A scleral lens is a large rigid gas-permeable lens that rests on the sclera (the white of the eye) and arches over the whole cornea without touching it. It is filled with sterile, preservative-free saline before it goes in.
For an eye that can’t close or blink properly, the lens:
- Keeps the cornea wet all day. The saline stays over the cornea for as long as the lens is worn, so it doesn’t depend on blinking to stay moist.[4]
- Shields the cornea from the air and from the friction of a lid that moves abnormally.[6]
- Can restore vision. Drops evaporate quickly and ointment blurs vision. A lens can keep the eye protected without the blur, and its saline layer smooths over a roughened or scarred cornea.[4]
- Sometimes supports the lid. A few reports describe custom lens designs that lifted a drooping upper lid (see below).[10]
What the research shows
Evidence is limited to case reports and small series. There are no trials of scleral lenses for facial palsy. For larger studies of exposure in general, see our exposure keratopathy page.
After acoustic neuroma surgery. One report described three patients (four eyes) with facial palsy after acoustic neuroma surgery, whose eyes still weren’t protected despite gold lid weights and, in two, a partly closed lid. Two had used thick ointment several times a day for about 15 years, with vision reduced to counting fingers. With mini-scleral lenses, their vision improved to about 20/30 and their pain and watering resolved. The third patient’s keratitis cleared within a week. All kept good vision over two years without side effects.[4]
Long-term wear with a numb cornea. A Belgian report followed three patients with lagophthalmos and loss of corneal feeling after acoustic neuroma or brain tumor surgery, for 3, 17, and 18 years. Two of them had asked for a tarsorrhaphy (a partly sewn-shut eyelid) to be opened because it limited their vision. Two wore the lenses full time and one up to 10 hours a day. All were told not to sleep in their lenses. Two eyes later needed a corneal transplant, and lens wear resumed 4 to 6 weeks afterward. The authors called the learning curve for insertion and removal the main obstacle, especially without corneal feeling.[5]
When eyelid surgery hasn’t been enough. A US oculoplastics clinic reviewed patients fitted with scleral lenses over 25 years. Sixteen had corneas that kept deteriorating despite eyelid procedures such as tarsorrhaphy and gold weights. Five had facial nerve palsy, and four had both facial and trigeminal (corneal sensation) nerve palsy. Fourteen of the 16 saw at least one line better with scleral lenses.[8] A case report of palsies of several cranial nerves on both sides, including the facial nerve, described substantial vision gains with scleral lenses after many other treatments had been tried.[7]
Lifting a drooping lid. In a series of nine patients with complex eyelid problems treated with PROSE scleral devices, all those with a drooping upper lid had a measurable lift, and 5 of 7 avoided further lid surgery.[9] A 2026 report described two older men with facial palsy and keratoconus fitted with custom lenses shaped differently in each quadrant. Their upper lids lifted by 2.5 mm each, their vision improved substantially, and one was followed for 42 months without lens problems.[10] These are very small numbers.
How patients see it. In a survey of 49 people attending a specialist facial nerve clinic, artificial tears and ointment were the most used and most satisfying measures. Only 2 had used a scleral lens. They rated it positively, but the authors said there was too little data to generalize.[11]
Other options, compared
Early eye care in facial palsy starts with frequent preservative-free lubricating drops, ointment, and night-time eye patching or a moisture chamber.[10] Taping the eye shut and moisture chambers are also used, and in one survey artificial tears and ointment were the most used measures, with the highest overall satisfaction.[11]
When exposure persists, surgical options include gold or platinum weights in the upper lid,[10] lateral tarsorrhaphy, lateral canthoplasty, and other procedures that tighten or lift the lids. When the nerve has been injured by surgery or a tumor, nerve repair or grafting may be possible, and muscle transfers can restore some movement in long-standing paralysis.[3] Botulinum toxin to cause a temporary protective droop of the upper lid, and lid springs, are other options.[6]
| Option | What it does | Typically suited to |
|---|---|---|
| Drops, gels, and ointment | Keep the surface lubricated | Everyone, especially early Bell’s palsy |
| Taping or moisture chamber | Covers or humidifies the eye, often at night | Night protection; short-term palsy |
| Botulinum toxin to the upper lid | Temporary droop that covers the cornea | Short-term protection while recovery is awaited |
| Gold or platinum lid weight | Helps the upper lid close by gravity | Lasting lagophthalmos |
| Tarsorrhaphy or lid tightening | Narrows or supports the lid opening | Persistent exposure; can limit vision and change appearance |
| Scleral lens | Keeps the cornea covered in saline by day | Lasting palsy, especially if other measures failed or vision is poor |
| Nerve repair or muscle transfer | Restores some facial movement | Selected patients with nerve injury or long-standing paralysis |
Questions to ask a scleral lens fitter
- How many patients with facial palsy or lagophthalmos do you fit?
- Is my palsy expected to recover, and does that change whether a lens makes sense now?
- What should I use to protect my eye at night?
- Is my cornea’s feeling reduced, and how will that change my follow-up?
- Can the lens be designed to help my eyelid position?
- How will you work with my oculoplastic surgeon if I also need lid surgery?
- What signs should make me remove the lens and call right away?
Common questions
I just developed Bell's palsy. Do I need a scleral lens?
Probably not right away. Most people with Bell's palsy recover on their own, and early eye care usually means lubricating drops, ointment, and protecting the eye at night. A scleral lens is more often considered when the palsy lasts, or when the cornea is being damaged despite those measures. Your eye doctor can tell you how well your eye is coping.
Can I sleep in the lens since my eye won't close?
In the long-term reports we found, patients were told not to sleep in their lenses. You will usually still need night protection, such as ointment, taping, or a moisture chamber. Ask your eye doctor what to use.
Can a scleral lens replace a gold weight or tarsorrhaphy?
For some people. Small reports describe scleral lenses used as a long-term alternative to partly sewing the eyelids closed, and to protect the eye when lid surgery hadn't been enough. For others, lid surgery is the better answer, or both are used together. The right choice depends on whether the palsy is expected to recover and what matters most to you.
My cornea is also numb after surgery. Does that change things?
Yes. A numb cornea heals poorly and may not hurt when something is wrong, so regular checks matter more than how the eye feels. It can also make learning to handle the lens harder. Our neurotrophic keratitis page explains more.
Can a scleral lens lift my drooping eyelid?
In a few published cases, a lens designed with extra clearance in the right places lifted the upper lid. This has only been reported in small numbers of patients, so treat it as a possible bonus rather than the reason to try a lens.