Eyelid closing and opening disorders in patients with unilateral brain lesions: A case report with video neuroimage and a systematic review of the literature


      • Unilateral brain lesions may cause eyelid closing and/or opening disorders.
      • There is a correlation between right hemisphere and eyelid motor control.
      • Different neural substrates underpin eyelid opening vs closing disorders.
      • Unilateral apraxia of eyelid closure may be related to intentional forms of neglect.
      • Subcortical structures may be more involved in eyelid opening vs closing disorders.


      Eyelid closing or opening disorders have been only sporadically described in patients with focal brain lesions over the last decades. Furthermore, the restricted number of reports and the lack of uniform clinical assessment of affected individuals did not allow to define more in depth the clinical features and the underlying neural correlates of these uncommon clinical disorders. Here we report an 89-years old woman with a right hemispheric lesion who showed a contralesional defect of eyelid closure. We also include a video neuroimage of this case and a review of eyelid closing and opening disorders in patients with focal unilateral lesions. In this review we found a correlation between right hemisphere and eyelid motor control, particularly for apraxia of eyelid closure affecting only the contralesional eye. The right parietal lobe was most frequently affected in this unilateral form of eyelid closing disorders, whereas putamen and other subcortical structures were more involved in eyelid opening than in eyelid closing disorders. The relations between unilateral eyelid closing disorders and other forms of motor-intentional defects are shortly discussed.


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        • Lewandowsky M.
        Über Apraxie des Lidschlusses.
        Berl Klin Wochenschr. 1907; 44: 921-923
        • Goldstein J.E.
        • Cogan D.G.
        Apraxia of lid opening.
        Arch Ophthalmol. 1965; 73: 155-159
        • Lepore F.E.
        • Duvoisin R.C.
        Apraxia of eyelid opening: an involuntary levator inhibition.
        Neurology. 1985; 35: 423-427
      1. Brusa A, Mancardi G, Meneghini S, Piccardo A, Brusa G. Apraxia of eye opening in idiopathic Parkinson's disease. Neurology 1986;36(1):134. doi: 10.1212/wnl.36.1.134.

        • Golbe L.I.
        • Lepore F.E.
        • Davis P.H.
        Eyelid movement abnormalities in progressive supranuclear palsy.
        Mov Disord. 1989; 4: 297-302
        • Lamberti P.
        • De Mari M.
        • Zenzola A.
        • Aniello M.S.
        • Defazio G.
        Frequency of apraxia of eyelid opening in the general population and in patients with extrapyramidal disorders.
        Neurol Sci. 2002; 23: S81-S82
        • Hamedani A.G.
        • Gold D.R.
        Eyelid dysfunction in neurodegenerative, neurogenetic, and neurometabolic disease.
        Front Neurol. 2017; 8: 329
        • Boghen D.
        Apraxia of lid opening: a review.
        Neurology. 1997; 48: 1491-1494
        • van Koningsbruggen M.G.
        • Peelen M.V.
        • Davies E.
        • Rafal R.D.
        Neural control of voluntary eye closure: a case study and an fMRI investigation of blinking and winking.
        Behav Neurol. 2012; 25: 103-109
        • Colombo A.
        • De Renzi E.
        • Gibertoni M.
        Eyelid movement disorders following unilateral hemispheric stroke.
        Ital J Neurol Sci. 1982; 3: 25-30
        • De Renzi E.
        • Gentilini M.
        • Bazolli C.
        Eyelid movement disorders and motor impersistence in acute hemisphere disease.
        Neurology. 1986; 36: 414-418
        • Miwa H.
        • Kagohashi M.
        • Noda K.
        • Miyashita N.
        • Tanaka S.
        • Mizuno Y.
        Eyelid motor extinction.
        J Neurol. 2001; 248: 343-344
      2. Belin C, Larmande J, Gaymard B, Larmande P. Loss of unilateral eye closure and right parietal lesion. J Neurol Neurosurg Psychiatry 1988;51(7):1008. doi: 10.1136/jnnp.51.7.1008.

        • Hamano T.
        • Kimura S.
        • Miyao S.
        • Teramoto J.
        Apraxia of eyelid closure complicating right parietal infarction.
        Eur Neurol. 2001; 45: 122-123
        • Korn T.
        • Reith W.
        • Becker G.
        Impaired volitional closure of the left eyelid after right anterior cerebral artery infarction: apraxia due to interhemispheric disconnection?.
        Arch Neurol. 2004; 61: 273-275
        • Pérez-Martínez D.A.
        • Puente-Muñoz A.I.
        • Doménech J.
        • Baztán J.J.
        • Berbel-Garcia A.
        • Porta-Etessam J.
        Apraxia unilateral del cierre palpebral tras un ictus isquémico: el papel del hemisferio derecho en la comunicacion gestual mocional [Unilateral apraxia of eyelid closure in ischemic stroke: role of the right hemisphere in the emotional gesture communication].
        Rev Neurol. 2007; 44: 411-414
      3. Thon JM, Grossmann L, Bhattacharyya S. Teaching Video NeuroImages: Apraxia of eyelid closure following right hemispheric infarction. Neurology 2017;89(2):e15. doi: 10.1212/WNL.0000000000004091.

        • Wada Y.
        • Kita Y.
        • Yamamoto T.
        Dissociation of voluntary eye closure–to keep the eyes closed and to blink–following right hemisphere stroke.
        No To Shinkei. 2000; 52: 529-533
      4. Aramideh M, Kwa IH, Brans JW, Speelman JD, Verbeeten B Jr. Apraxia of eyelid closure accompanied by denial of eye opening. Mov Disord 1997;12(6):1105–8. doi: 10.1002/mds.870120651.

        • Monaco F.
        • Pirisi A.
        • Sechi G.P.
        • Cossu G.
        Acquired ocular-motor apraxia and right-sided cortical angioma.
        Cortex. 1980; 16: 159-167
      5. Rosati G, De Bastiani P, Granieri E, Agnetti V. Voluntary lid closing inability. Release of a compulsive reaction to the exploration of the environment. Arch Psychiatr Nervenkr (1970) 1978;226(1):11–7. doi: 10.1007/BF00344119.

        • Fisher M.
        Left hemiplegia and motor impresistence.
        J Nerv Ment Dis. 1956; 123: 201-218
        • Dehen H.
        • Cambier J.
        Non fermeture volontaire des paupières, impersistance motrice et spécialisation fonctionnelle hémisphérique [Failure of voluntary eyelid closure, motor impersistence and hemispheric functional specialization. A report on 3 cases (author's transl)].
        Rev Neurol (Paris). 1979; 135: 573-582
        • Papagno C.
        • Della S.S.
        Crossed face apraxia.
        J Neurol Neurosurg Psychiatry. 2000; 69: 694-695
      6. Ghika J, Regli F, Assal G, Bogousslavsky J. Impossibilité à la fermeture volontaire des paupières. Discussion sur les troubles supranucléaires de la fermeture palpébrale à partir de 2 cas, avec revue de la littérature [Inability to voluntarily close the eyes. Discussion of supranuclear disorders in palpebral closure based on 2 cases, with a review of the literature]. Schweiz Arch Neurol Psychiatr (1985) 1988;139(6):5–21.

        • Ferro F.M.
        • Anepeta L.
        • Maurillo M.
        Considerazioni su due casi di “aprassia” della chiusura e dell'apertura degli occhi [On 2 cases of “apraxia” of opening and closing the eyes].
        Riv Patol Nerv Ment. 1969; 90: 300-308
        • Larmande P.
        • Larmande A.
        • Rolland J.
        Perte de l'occlusion volontaire unilatérale des paupières et impersistance motrice palpébrale par lésion pariétale tumorale [Loss of unilateral voluntary closing of the eyelids and palpebral motor impersistence as a result of a parietal tumor lesion].
        Rev Otoneuroophtalmol. 1983; 55: 77-83
        • Hirose M.
        • Mochizuki H.
        • Honma M.
        • Kobayashi T.
        • Nishizawa M.
        • Ugawa Y.
        Apraxia of lid opening due to a small lesion in basal ganglia: two case reports.
        J Neurol Neurosurg Psychiatry. 2010; 81: 1406-1407
        • Kaiboriboon K.
        • Oliveira G.R.
        • Leira E.C.
        Apraxia of eyelid opening secondary to a dominant hemispheric infarction.
        J Neurol. 2002; 249: 341-342
        • Waragai M.
        • Shinotoh H.
        • Kaneko M.
        • Hattori T.
        Difficulty in eye opening following left hemispheric infarction– causative lesion and pathophysiology of abnormalities of the eye and eyelids movements.
        Rinsho Shinkeigaku. 1996; 36: 577-583
        • Johnston J.C.
        • Rosenbaum D.M.
        • Picone C.M.
        • Grotta J.C.
        Apraxia of eyelid opening secondary to right hemisphere infarction.
        Ann Neurol. 1989; 25: 622-624
        • Algoed L.
        • Janssens J.
        • Vanhooren G.
        Apraxia of eyelid opening secondary to right frontal infarction.
        Acta Neurol Belg. 1992; 92: 228-233
        • Sakajiri K.
        • Matsubara N.
        • Nakajima T.
        • Fukuhara N.
        • Bandoh M.
        A case of “apraxia of eyelid opening” secondary to right hemisphere infarction–assessment of various symptoms of the eye and eyelid.
        Rinsho Shinkeigaku. 1995; 35: 164-168
        • Lee S.S.
        • Lee H.S.
        Can subcortical infarction cause apraxia of eyelid opening?.
        J Clin Neurosci. 2011; 18: 1399-1400
        • Hsieh C.Y.
        • Sung P.S.
        • Hwang W.J.
        Transient blepharospasm, apraxia of eyelid opening, and hemidyskinesia following a right parietotemporal infarct.
        Parkinsonism Relat Disord. 2014; 20: 1024-1026
        • Lin Y.H.
        • Liou L.M.
        • Lai C.L.
        • Chang Y.P.
        Right putamen hemorrhage manifesting as apraxia of eyelid opening.
        Neuropsychiatr Dis Treat. 2013; 9: 1495-1497
        • Kinoshita H.
        • Maki T.
        • Hata M.
        • Nakayama Y.
        • Yamashita H.
        • Sawamoto N.
        • et al.
        Convergence paralysis caused by a localized cerebral infarction affecting the white matter underlying the right frontal eye field.
        J Neurol Sci. 2017; 375: 94-96
        • Nutt J.G.
        Lid abnormalities secondary to cerebral hemisphere lesions.
        Ann Neurol. 1977; 1: 149-151
      7. Verghese J, Milling C, Rosenbaum DM. Ptosis, blepharospasm, and apraxia of eyelid opening secondary to putaminal hemorrhage. Neurology 1999;53(3):652. doi: 10.1212/wnl.53.3.652-a.

        • Suzuki Y.
        • Kiyosawa M.
        • Ohno N.
        • Mochizuki M.
        • Inaba A.
        • Mizusawa H.
        • et al.
        Glucose hypometabolism in medial frontal cortex of patients with apraxia of lid opening.
        Graefes Arch Clin Exp Ophthalmol. 2003; 241: 529-534
        • Heilman K.M.
        Intentional neglect.
        Front Biosci. 2004; 9: 694-705
        • Heilman K.M.
        • Van Den Abell T.
        Right hemispheric dominance for mediating cerebral activation.
        Neuropsychologia. 1979; 17: 315-321
        • Verfaellie M.
        • Bowers D.
        • Heilman K.M.
        Hemispheric asymmetries in mediating intention, but not selective attention.
        Neuropsychologia. 1988; 26: 521-531
        • Kertesz A.
        • Nicholson I.
        • Cancelliere A.
        • Kassa K.
        • Black S.E.
        Motor impersistence: a right-hemisphere syndrome.
        Neurology. 1985; 35: 662-666
        • Ragasudha B.
        • Ramani A.
        • Yadav R.
        Apraxia of eyelid closure in a case of post-Japanese encephalitis Parkinsonism.
        Neurol India. 2016; 64: 547-549
        • Cardoso F.
        Botulinum toxin in Parkinsonism: The when, how, and which for botulinum toxin injections.
        Toxicon. 2018; 147: 107-110