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And So to Sleep: Hypnotherapy forLagophthalmosJean Holroyd Ph.D. a & Ezra Maguen aa University of California , Los Angeles, USAPublished online: 21 Sep 2011.

To cite this article: Jean Holroyd Ph.D. & Ezra Maguen (1989) And So to Sleep:Hypnotherapy for Lagophthalmos, American Journal of Clinical Hypnosis, 31:4, 264-268, DOI:10.1080/00029157.1989.10402782

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AMERICAN JOURNAL OF CLINICAL HYPNOSIS

VOLUME 31, NUMBER 4, APRIL 1989

And So To Sleep: Hypnotherapy forLagophthalmos

Jean Holroydand

Ezra MaguenUniversity of California, Los Angeles

We used hypnosis to facilitate eye closure during sleep for a 44-year-old womanwhose nocturnal lagophthalmos prevented use of a contact lens following cat­aract surgery and could have resulted in severe corneal damage. On threeseparate occasions the symptoms remitted following a very brief course oftreatment. We discuss the results in terms of alternate theories of hypnoticperformance.

Sometimes patients request hypno­therapy for strange or exotic conditionsthat do not appear to be amenable to othertreatments. This kind of request for treat­ment came from a 44-year-old profes­sional photographer whose inability toclose her eyelids at night was responsiblefor corneal irritation and corneal erosion.On the basis of history and clinical find­ings, the second author made a diagnosisof nocturnal lagophthalmos.

Lagophthalmos is a condition wherebylid closure is incomplete, either becauseof under action of the upper lid or retrac-

Received November 20, 1987; revised May20, 1988; accepted for publication January 2,1989.

For reprints write to Jean Holroyd, Ph.D.,Department of Psychiatry, UCLA Schoolof Medicine, 760 Westwood Plaza, LosAngeles, CA 90024.

tion of the lower lid. It most frequentlyoccurs in association with thyroidophthalmopathy but also occurs with ec­tropion, conjunctival cicatricial diseases,facial nerve palsy, tumors involving theseventh nerve nucleus, and various orbitalspace-occupying lesions. In addition, lag­ophthalmos may occur in an idiopathicfashion, usually at night, leading to thedesignation nocturnal lagophthalmos(Sturrock, 1976). The diagnosis of lag­ophthalmos is made by history and by thepresence of inferior keratopathy due todrying. Treatment includes protection ofthe cornea by patching, lubricants, andtherapeutic soft contact lenses. Existingunderlying causes are treated medically orsurgically.

The patient had been an early-onset,insulin-dependent diabetic for 34 years.She underwent no ophthalmic examina­tions until age 23, at which time an intra­ocular hemorrhage occurred in the left eye,

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HYPNOTHERAPY FOR LAGOPHTHALMOS

followed shortly afterwards by two addi­tional hemorrhages. Because of the pres­ence of bilateral, florid, proliferativediabetic retinopathy, a hypophysectomywas performed in an effort to control theretinopathy. An improvement was notedin the right eye, yet the left eye remainedwith low vision and subsequently devel­oped epiretinal membranes and a maturecataract. At age 28 she sustained two ad­ditional episodes of bleeding and as a re­sult underwent focal laser photocoagulationin the right eye, after which both retinasremained stable. The best corrected rightvision range was 20/25 to 20/40. The bestcorrected left vision was hand movementat one meter. As a result of the hypophy­sectomy, the patient became panhypopi­tuitary, requiring hormonal replacements.Her diabetes was stable and she was in­sulin dependent.

At age 36 the patient presented with anacute episode of bilateral ocular pain withsevere light sensitivity. Best corrected vi­sion was 20/30 in the right eye and lightperception in the left. The extraocularmuscle function was intact without re­striction, and the interpalpebral fissurewidth was within normal limits in botheyes, with no exophthalmos. Voluntarylid closure was adequate without expo­sure and with a decreased Bell's phenom­enon. Forceful lid closure was adequate.Superficial punctate keratopathy waspresent in the right eye, and a cornealepithelial defect of about 5 mm was pres­ent in the left lower cornea. Moderatecorneal edema was present bilaterally.Corneal sensation was adequate. TheSchirmer test with anesthetic showed 20mm of wetting in the right eye and a fullstrip of wetting in the left (normal val­ues). The patient volunteered that she hadbeen seen sleeping with her eyes open andhad used patches and ocular lubricants in

265

the past to alleviate milder ocular pain inthe morning. Based on the clinical find­ings and history, the working diagnosiswas nocturnal lagophthalmos versus dia­betic epithelial corneal disease.

The initial treatment was patching, lu­bricants, therapeutic soft contact lenses,and nonpreserved cellulose gum eye drops.Despite all of the above, lagophthalmicepisodes recurred four times, remitting onlywhen she received brief hypnotherapy.Symptom remission lasted 3 years, atwhich time the patient experienced tworecurrences of the lagophthalmos. She re­quested hypnosis from the first author be­cause her previous hypnotherapist was nolonger available to her. Three sessions ofhypnosis with suggestions similar to thosegiven by her previous therapist (that hereyelids would be comfortably held shutby tiny magnets) permitted her to returnto satisfactory functioning.

The lagophthalmos reoccurred 5 yearslater, prompting a return to the first au­thor. The patient had recently undergonea left extracapsular cataract extraction inorder to attempt to improve her peripheralvision in that eye for driving purposes.The surgery and the postoperative coursewere uneventful. A contact lens was rec­ommended if she could learn to keep hereyelids closed at night. During sleep thelids invariably separated, permitting thecornea to dry out.

Optimistically, we began hypnosistreatment again for the lagophthalmos, andthe patient requested inclusion of sugges­tions about her eyes producing more tears.(The sensation of dry eyes, usually re­ferred to as foreign body sensation or FBS,is a secondary symptom due to lago­phthalmos. As the Schirmer's test indi­cated, tear production for this patient wasnormal. The only reason she felt dryness,particularly in the morning, was because

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of the inability of the tears to wet the cor­nea properly during sleep.)

The patient completed the SpielbergerState-Trait Anxiety measures (Spielberg­er, Gorsuch, & Lushene, 1970), scoringat the 48th and 57th percentiles of Gen­eral Medical Samples, respectively. Shescored 21 on the Tellegen AbsorptionScale, which is the 54th percentile on col­lege student norms (Tellegen, 1982). Thetest results indicate anxiety levels withinthe normal range and an average pro­pensity for becoming absorbed in ima­ginal and sensory experiences such ascharacterize hypnosis.

We began hypnosis sessions with sug­gestions that she could sleep very com­fortably all night long with her eyelidscompletely closed. After four one-hourappointments she was seen for seven half­hour appointments. Suggestions were alongthe following lines:

Your eyes can be completely closed whilesleeping; they can close completely whenyou blink. Your eyelids can be comfortablyclosed all night, with your lids as if theywere sealed. The part of your brain (or backof your mind) that takes care of your body(for eating, drinking, urinating) will keepyour eye closed while you sleep. You willsleep very deeply, comfortably, with youreyes completely closed, like your cats.

When you are deeply relaxed your bodyfunctions optimally. Your eyes can producemore tears, just like actors and actresses.Tears will flow more liberally. They can behappy or neutral tears; they don't have toimply unhappiness. Your body takes in alot of liquid, which goes into producingurine, sweat, blood, tears; it can secretemore tears. Your eyes will be very com­fortable with the tear ducts producing morefluid. The ducts will become more active,alive, youthful; will produce more fluid likewhen you have a happy emotion-seeing ababy, a little kitten or a little puppy. Theducts will produce more and more liquid,

HOLROYD AND MAGUEN

day and night, and that will feel very com­fortable to you. Your eyes will float verycomfortably in that healthy liquid. Whenyour eyes move during dreaming they willbe bathed in fluid.

Permissive amnesia suggestions wereusually given:

You don't have to pay conscious atten­tion to what I'm saying because what I sayis taken in by your unconscious mind. Asthis material drifts into the back of yourmind, you may forget it in your consciousmind. As you forget with your consciousmind, you'll know that it's in your uncon­scious mind. You mayor may not remem­ber what I have said; I have been talking toa deeper part of yourself.

In the third session, the patient re­quested retraining in self-hypnosis, whichshe had successfully carried out before.During the fourth session a very brief tapewas made, including suggestions for re­laxation, permissive suggestions for timeand space dissociation, permissive am­nesia suggestions, and the direct sugges­tion that her eyelids would be comfortablyclosed while she slept. I instructed thepatient to use the tape or self-hypnosisdaily. She reported that she tended to usethe tape every night at bedtime. She notedthat she felt more of a difference in hereyes on mornings after she had played thetape than on mornings when she hadn't.The most meaningful imagery used inheterohypnosis, according to the patient,was that of sleeping like her cats.

At the beginning of treatment and be­fore sessions 4 through 11, the patient re­corded symptoms of eyes not closing (e.g.,irritation) on a lO-cm line (see Figure 1).She estimated that the lagophthalmos hadbeen most severe (a rating of 10) beforethe first use of hypnosis several years ear­lier. Baseline upon entering this treatmentwas rated 5.5. She rated the week aftersession five as 1.5, and she was fitted

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HYPNOlliERAPY FOR LAGOPHTHALMOS 267

7>- • Lagophthalmos~ 6- • Moisturea:::w 5>wen 4~

30~c, 2~>-en

0

2 3 4 5 6 7 8 9 10 11 F

SESSIONFigure 1

Subjective symptom severity as a function of number of treatment sessions. "Moisture" refers toabsence of a foreign body sensation. "F" represents the follow-up session 16 months after treatment

termination.

with an aphakic contact lens after sessionseven, achieving adequate peripheral vi­sion. (She reported that she was seeingbetter than she had been able to see withthat eye for most of her adult life.) Be­cause improvement in FBS was limited,in the eighth session we added a separatesymptom measure for the subjective senseof dryness versus moisture, beginning witha baseline rating of 4.5. At the patient'srequest we made a shorter tape for bothsymptoms. The symptom rating for lag­ophthalmos itself remained very low foralmost a month, after which it took anunexpected turn upward prior to herscheduled last visit. The patient thoughtthe setback was temporary, due to fluidsused for cleaning her lenses, and she wasplanning to get a nonirritating lens cleaner.

The patient did not keep a 3-week fol­low-up appointment. However, she read­ily came in for a follow-up 16 monthslater, when we learned that the achievedresults had been maintained throughout thatperiod (see Figure 1). At the follow-upsession the patient scored 7 on the Stan­ford Hypnotizability Scale, Form C(Weitzenhoffer & Hilgard, 1962), placingher in the middle range of hypnotizabil­ity.

Discussion

There was an excellent correlation be­tween the onset of hypnotherapy and thecessation of the recurrent corneal erosionsecondary to nocturnal lagophthalmos.Healing of corneal erosion, disappearanceof the superficial punctate keratopathy, and

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alleviation of ocular foreign body sensa­tion occurred promptly following hyp­notherapy (with two separate therapists).Positive response to hypnosis bears re­semblance to the positive response ob­tained with other functional muscleproblems such as bruxism and enuresis(Kroger, 1977). However, we could lo­cate no published reports on hypnosistreatment of lagophthalmos using stan­dard search procedures. 1

Kihlstrom (1985) notes that hypno­therapy may be more successful wherehypnotic treatment capitalizes on theprocesses that are central to hypnosis. Inthis case, heightened suggestibility, morevivid imagery, and more specific influ­ence of thoughts upon organ systemsprobably came into play (Brown & Fromm,1986; Holroyd, 1987). Social influenceexplanations (role taking, expectancy,compliance) seem less relevant as expla­nations. This highly motivated patient hadnot been able to keep her eyes closed dur­ing sleep despite her conscious efforts,her "good-patient" role, her positive ex­pectations about the benefits of standardtreatments, and respectful incorporationof the assistance provided by her ophthal-

I Medlars search of articles from 1966 to pres­ent, the Cumulative Index of the American Jour­nal of Clinical Hypnosis from 1958 (Volume 1)through 1966, and annual indices of the Journalof Clinical and Experimental Hypnosis from 1959(Volume 7) through 1965.

HOLROYD AND MAGUEN

mologist. The ability to use information(instructions, imagery, metaphor) at abiological level seems to have been en­hanced by cognitive, affective, and mo­tivational aspects of an altered state ofconsciousness.

ReferencesBrown, D. P. & Fromm, E. (1986). Hypno­

therapy and hypnoanalysis. Hillsdale, NJ:Lawrence Erlbaum Associates.

Holroyd, J. (1987). How hypnosis may po­tentiate psychotherapy. American Journalof Clinical Hypnosis. 29. 194-200.

Kihlstrom, J. F. (1985). Hypnosis. AnnualReview of Psychology, 36, 385-418.

Kroger, W. S. (1977). Clinical and experi­mental hypnosis in medicine, dentistry, andpsychology. Philadelphia: J. B. LippincottCo.

Spielberger, CD, Gorsuch, R. L., & Lush­ene, R. E. (1970). Manual for the State­Trait Anxiety Inventory. Palo Alto, CA:Consulting Psychologists Press.

Sturrock, G. D. (1976). Nocturnallagophthal­mos and recurrent erosions. British Journalof Ophthalmology, 60, 97-103.

Tellegen, A. (1982). Briefmanual for the Dif­ferential Personality Questionnaire. Un­published manual. Available from AukeTellegen, Department of Psychology, El­liott Hall, University of Minnesota, Min­neapolis, MN 55455.

Weitzenhoffer, A. M. & Hilgard, E. R. (1962).Stanford Hypnotic Susceptibility Scale, FormC. Palo Alto, CA: Consulting PsychologistsPress.

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