Journal of Clinical Neuroscience 87 (2021) 69–73

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience
journal homepage: www.elsevier.com/locate/jocn

Review article

Eyelid closing and opening disorders in patients with unilateral brain
lesions: A case report with video neuroimage and a systematic review of
the literature
Tommaso Nicoletti a,b,⇑, Davide Quaranta b, Giacomo Della Marca a,b, Giorgio Tasca b, Guido Gainotti a
a
b

Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
UOC Neurologia, Fondazione Policlinico Universitario ‘‘A. Gemelli” IRCSS, Rome, Italy

a r t i c l e

i n f o

Article history:
Received 6 January 2021
Accepted 15 February 2021

Keywords:
Eyelid movement disorders
Eyelid apraxia
Eyelid closing apraxia
Eyelid opening apraxia
Right hemisphere
Intentional neglect

a b s t r a c t
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 motorintentional defects are shortly discussed.
Ó 2021 Elsevier Ltd. All rights reserved.

1. Introduction
The hypothesis that distinct brain areas may be responsible on
the one hand for voluntary eyelid movements such as bilateral lid
opening/closing or unilateral winking and, on the other hand, for
involuntary blinking has already emerged from the first descriptions of patients with eyelid closure [1] and opening [2] disorders.
The observed dissociation between sparing of the automatic and
impairment of the voluntary eyelid movements suggested to
Lewandowsky [1] and Golstein [2] the use of the term apraxia of
eyelid closing (AEC) and, respectively, of eyelid opening (AEO)
and these terms have been subsequently widely used in the ad
hoc literature.
The inability to close or open the eyes on command raised
widespread attention in the field of neurodegenerative disorders,
in particular of extrapyramidal disorders with respect to AEO
(e.g. [3–7]). Conversely, individuals affected by focal brain lesions
with explicit mention of AEC and/or AEO have been less frequently
reported, leaving unsolved the following issues concerning AEC
⇑ Corresponding author at: UOC Neurologia, Fondazione Policlinico Universitario
‘‘A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Roma, Italy.
E-mail address: tommasof.nicoletti@gmail.com (T. Nicoletti).
https://doi.org/10.1016/j.jocn.2021.02.020
0967-5868/Ó 2021 Elsevier Ltd. All rights reserved.

and AEO in patients with unilateral brain lesions: it is not clear
whether the same supranuclear neural circuits are responsible
both for eyelid closure and opening disorders (see [7–9] for
reviews), even if it is well known that the orbicularis oculi muscle,
which controls eyelid closure, is innervated by the facial nerve,
whereas the levator palpebrae superioris muscle, which controls
eyelid opening, is innervated by the oculomotor nerve. It is also
debated if there are functional hemispheric asymmetries upstream
these two phenomena, even if most authors (e.g. [10,11]) acknowledge that these disorders are significantly more frequent after right
than left brain damage. It is equally still unclear if apraxia of eyelid
closure affects both eyes or if it can selectively affect only the contralateral eye and, in this case, if there is any hemispheric dominance [9–11]. Another intriguing challenge consists in
establishing which are the lobes most often involved in case of eyelid opening or closure apraxia, because both the frontal (e.g. [9,12])
and the parietal lobe (e.g. [10,11,13,14]) have been reported as
more frequently affected.
We recently observed a patient who developed a complete
inability to close the left eye on command after a right-sided
fronto-insular brain ischaemia (a neuroimage video is enclosed in
Appendix). We, therefore, tried to systematically review the litera-

T. Nicoletti, D. Quaranta, G. Della Marca et al.

Journal of Clinical Neuroscience 87 (2021) 69–73

command 2) Preserved ability to blink spontaneously or after
visual threat.
Patients with eyelid closing and opening disorders were
included if the symptom’s onset was acute and in association with
a unilateral brain lesion. We decided also to include one patient
with bilateral cerebral lesions and unilateral (left) eyelid closure
deficit due to a large right-hemispheric lesion [9], because of the
peculiar clinical manifestation.

ture to clarify the main behavioural and neuro-anatomical aspects
of eyelid closing and opening apraxia.
2. Case report
An 89-years old woman presented with a right hemispheric
stroke involving fronto-opercular and posterior insular cortices.
Neurological examination showed a cooperative patient, oriented
to time and place, whose spontaneous speech was characterized
by reduced fluency and dysprosody. The patient also showed
left–right disorientation. Ocular movements were normal, but
she could not close her left eye on command [video]. Sleeping with
both eyes closed and spontaneous blinking were possible. She was
also able to maintain the left eye closed after manual lowering of
eyelids. She had left central facial palsy, mild dysarthria and dysphagia with liquids. Neither signs of lower facial apraxia nor of
ideomotor apraxia were observed. Sensibilities and motor functions were normal.

3.2. Variables considered
We took into account information concerning the following
variables: age, sex, clinical characteristics (motor, sensory, visual
field defects, presence of anosognosia, neglect), hemispheric side
of the lesion and involved cerebral lobes. These key features are
analytically reported for each patient included in our review in
Appendix 1.
3.3. Statistical analysis

3. Review of the literature

The distribution of lesion location and clinical features were
assessed by binomial tests performed for the three main groups
of cases reported in previous studies: unilateral AEC, bilateral
AEC and AEO. Since all the variables were dichotomous in nature
(i.e., coded as present/absent), the test proportion for casual occurrence was set to 0.5. The comparison between groups was made
determining the chi quare statistic, with Fisher’s exact test as
requested.

3.1. Study setting and methods
To clarify the questions listed in the Introduction, we took into
account in the present review all studies found in the literature
which investigated the neural correlates of eyelid closing and
opening disorders in patients with unilateral brain lesions between
1907 (year of Lewandowsky’s original report) and 2020. With this
aim in mind, we used PubMed and Medline to search for studies
that included the following keywords: ‘‘eyelid closure” or ‘‘eyelid
opening” in conjunctions with ‘‘stroke”, ‘‘cerebrovascular disorders”, ‘‘focal brain lesions” and ‘‘apraxia” or ‘‘disorders”. We also
went through the bibliography of case reports and group studies
and added other cases, which were not present in the Medline
database using the over mentioned search criteria. In this manner
we assembled a cohort of 52 patients with explicit mention of eyelid closure and opening apraxia and unilateral brain lesions.
Eyelid closure or opening apraxia was defined by the presence
of two key criteria: 1) inability to close or open the eyes on

4. Results of the review
Forty-four (84.6%) of the fifty-two patients taken into account
(51 reported in literature and the one we have described) suffered
from right hemispheric lesions. The etiology of lesions is schematically depicted in Table 1. The most frequent disturbance was AEC
(34 patients, 19 bilateral and 15 unilateral), while patients with
AEO were 18. Two patients with right hemispheric lesions had
both AEC and AEO.
Almost all patients (32/34) with AEC had right hemispheric
lesions. In 12 out of 18 patients with AEO a right hemispheric
lesion was documented, while only six patients showed a leftbrain damage. All patients with AEO were unable to open both
eyes.
As shown in Table 2, in both unilateral and bilateral AEC we
found a prevalence of right hemisphere lesions (p < 0.001 for unilateral AEC, p = 0.001 for bilateral AEC) and of motor defects
(p = 0.001 for unilateral AEC, p = 0.021 for bilateral AEC). In unilat-

Table 1
Eyelid closing and opening disorders due to unilateral brain lesions.
Etiology

Patients No.

Stroke
CNS neoplasm

49
3

Table 2
Neuroanatomical and clinical correlates of unilateral and bilateral AEC.
Unilateral AEC

Right hemisphere
Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
Insula
Subcortical
Unilateral spatial neglect
Hemianopia
Motor deficit
Sensitive deficit
Anosognosia

Bilateral AEC

Present

prop

Absent

Prop

p*

Present

prop

Absent

prop

P*

15
10
5
12
2
5
1
4
7
14
8
6

1.00
0.67
0.33
0.80
0.13
0.33
0.07
0.27
0.47
0.93
0.53
0.40

0
5
10
3
13
10
14
11
8
1
7
9

0.00
0.33
0.67
0.20
0.87
0.67
0.93
0.73
0.53
0.07
0.47
0.60

<0.001
0.302
0.302
0.035
0.007
0.302
0.001
0.118
1.000
0.001
1.000
0.607

17
10
4
10
0
1
2
3
7
13
7
1

0.89
0.63
0.25
0.63
0.00
0.06
0.13
0.19
0.44
0.81
0.47
0.06

2
6
12
6
16
15
14
13
9
3
8
15

0.11
0.38
0.75
0.38
1.00
0.94
0.88
0.81
0.56
0.19
0.53
0.94

0.001
0.454
0.077
0.454
<0.001
0.001
0.004
0.021
0.804
0.021
0.804
0.001

Prop: proportion; * binomial test.
Bold values denote statistical significance.
70

Journal of Clinical Neuroscience 87 (2021) 69–73

T. Nicoletti, D. Quaranta, G. Della Marca et al.

AEO was negatively correlated with lesions in insula (p = 0.001)
or occipital lobe (p < 0.001), and with the presence of anosognosia
for left-sided hemiplegia (p = 0.001). When a comparison was
made between AEC (both unilateral and bilateral) and AEO, as
shown in Table 5, the prevalence of right hemisphere lesions was
higher in AEC, whereas lesions of subcortical structures were more
common in patients with AEO.

eral AEC we also found a significant prevalence of lesions in the
parietal lobe (p = 0.035). A prevalence of lesions in the parietal lobe
was equally found in patients with bilateral AEC, but this difference was not significant (p = 0.454). On the other hand, a negative
correlation was found between presence of unilateral AEC and
lesion of the occipital lobe (p = 0.007) or of subcortical structures
(p = 0.001) and a similar negative correlation was found between
bilateral AEC and lesions in occipital lobe (p < 0.001), subcortical
structures (p = 0.004) and insula (p = 0.001). When bilateral and
unilateral AEC were compared (Table 3), only the prevalence of
anosognosia for left-sided hemiplegia was significantly higher
(6/15, 40%, vs 1/19, 6.25%; p = 0.037) in patients with unilateral
AEC. In patients with AEO (Table 4), only the prevalence of motor
defects was significant (p = 0.035). Furthermore, the presence of

5. Discussion
Data observed in our patient are consistent with those obtained
by the literature review, which clearly indicate a dominant role of
the right hemisphere in voluntary eyelid control (e.g. [9–14]).

Table 3
Comparison of clinical and neuroanatomical features between unilateral and bilateral AEC.

Right hemisphere
Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
Insula
Subcortical
Unilateral spatial neglect
Hemianopia
Motor deficit
Sensitive deficit
Anosognosia

Unilateral

%

Bilateral

%

chi2

p

15
10
5
12
2
5
1
4
7
14
8
6

100.00
66.67
33.33
80.00
13.33
33.33
6.67
26.67
46.67
93.33
53.33
40.00

17
10
4
10
0
1
2
3
7
13
7
1

89.47
62.50
25.00
62.50
0.00
6.25
12.50
18.75
43.75
81.25
46.67
6.25

0.20
0.06
0.26
1.15
2.28
3.64
0.30
0.28
0.03
1.01
0.29
5.04

0.492
1.000
0.704
0.433
0.226
0.083
1.000
0.685
1.000
0.600
0.724
0.037

Bold values denote statistical significance.

Table 4
Neuroanatomical and clinical correlates of bilateral AEO.
Bilateral AEO

Right hemisphere
Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
Insula
Subcortical
Unilateral spatial neglect
Hemianopia
Motor deficit
Sensitive deficit
Anosognosia

Present

prop

Absent

prop

p

12
10
7
8
0
1
8
6
6
12
4
1

0.67
0.59
0.44
0.50
0.00
0.06
0.50
0.40
0.40
0.80
0.25
0.06

6
7
9
8
16
15
8
9
9
3
12
15

0.33
0.41
0.56
0.50
1.00
0.94
0.50
0.60
0.60
0.20
0.75
0.94

0.238
0.629
0.804
1.000
<0.001
0.001
1.000
0.607
0.607
0.035
0.077
0.001

Bold values denote statistical significance.

Table 5
Comparison of clinical and neuroanatomical features between AEC and AEO.

Right hemisphere
Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
Insula
Subcortical
Unilateral spatial neglect
Hemianopia
Motor deficit
Sensitive deficit
Anosognosia

AEC*

%

AEO

%

chi2

p

32
20
9
22
2
6
3
7
14
27
15
7

94.12
64.52
29.03
70.97
6.45
19.35
9.68
22.58
45.16
87.10
50.00
22.58

12
10
7
8
0
1
8
6
6
12
4
1

66.67
58.82
43.75
50.00
0.00
6.25
50.00
40.00
40.00
80.00
25.00
6.25

6.81
0.15
1.02
2.01
1.08
1.43
9.57
1.51
0.11
0.40
2.40
1.99

0.015
0.761
0.347
0.206
0.541
0.396
0.004
0.299
1.000
0.667
0.209
0.234

*Including both unilateral and bilateral AEC.
71

T. Nicoletti, D. Quaranta, G. Della Marca et al.

Journal of Clinical Neuroscience 87 (2021) 69–73

extrapyramidal) disorders, the inability to open the eyes on command has found therapeutic applications [45,46] and stimulated
much more research (e.g. [3–8]) than eyelid closing disorders.

Results of the review seem also to suggest a gradient in this right
hemisphere prevalence as a function of the eyelid (closing vs opening) movements and of the unilateral vs bilateral closure of the
eyelids. All the 15 patients who showed an eyelid closing defect
restricted to the contra-lesional eye had, indeed, a right hemisphere lesion, whereas a similar hemispheric lesion was observed
in 90% (17 out of 19) patients presenting a bilateral eyelid closing
defect and in 67% (12 out of 18) patients showing a bilateral eye
opening defect. In the last case the right hemisphere prevalence
was not statistically significant. More clear differences between
the different forms of eyelid closing and opening disorders were
observed when we took into account the intra-hemispheric locus
of damage and the associations with other neurological or neuropsychological defects. As for the neural substrate of the different
forms of eyelid closing or opening disorders, the only common
characteristic concerned a negative correlation with the occipital
lesions, suggesting (as expected) that the most caudal brain structures were not involved in eyelid movements. On the contrary, a
positive correlation with a lobar damage was observed only for
eyelid closing defects restricted to the contralesional eye, because
in this case a significant prevalence of parietal lobe lesions was
detected. A similar prevalence of lesions in the parietal lobe was
also found in patients with bilateral AEC, but this difference was
not significant. Moreover, when a comparison was made between
the neural substrate of all forms of AEC and all forms of AEO,
lesions of subcortical structures were more common in patients
with AEO than in those with AEC. With respect to the associations
with other neurological or neuropsychological disorders, the only
common characteristic regarded a positive correlation between
eyelid closing and opening defects and other defects of voluntary
movement. Furthermore, anosognosia for hemiplegia, was
observed more frequently in patients with unilateral -than in those
with bilateral- forms of AEC and in AEO. The contralesional location of the unilateral forms of AEC, their neural substrate (right
parietal) and their association with anosognosia for hemiplegia
could suggest a relation with the unilateral attentional disorders
typical of unilateral spatial neglect. Several theoretical and empirical reasons argue, however, against this hypothesis. The first is
that no significant association (and even no trend) was observed
between unilateral forms of AEC and unilateral spatial neglect.
The second is that eyelid closing defects play no role in disorders
of contralesional orienting of attention typical of unilateral spatial
neglect. The third is that the correlations observed between all
forms of eyelid closing or opening disorders and other defects of
voluntary movement seem to suggest that these eyelid movement
disorders might be linked more to motor-intentional than to
sensory-attentional defects. Heilman [41] has, indeed, noticed that
a failure to report, respond or orient to novel or meaningful stimuli
presented to the side opposite of a brain lesion, typical of the
neglect syndrome, can be induced by both attentional and intentional deficits. The same author has also claimed that the functions
of the intentional system in many respects parallel those of the
attention system, hence intentional deficits often have parallels
to attentional deficits. Heilman et al. [42,43] have also reported
data suggesting a right hemisphere dominance mediating intention. Support to the hypothesis assuming that the unilateral forms
of AEC may be linked to motor-intentional defects also comes by
the frequent observation (e.g. [10,11,13,14]) of an association
between unilateral or bilateral forms of AEC and motor impersistence, which is considered as a typical kind of motor-intentional
disorder [44].
On the other hand, a different pathophysiology of eyelid closing
and opening disorders is suggested by the observation that putamen and other subcortical structures were more involved in AEO
than in AEC patients. This finding is in accordance with the observation that in the field of neurodegenerative (and in particular of

6. Conclusions
In conclusion, results of our review seem to suggest that in
patients with unilateral brain lesions different mechanisms and
different neural substrates underpin AEO versus unilateral and
bilateral forms of AEC. Eyelid opening disorders could, indeed, be
closely related to the broader category of the movement disorders,
whereas unilateral forms of AEC could be related to the unilateral
(intentional) forms of neglect strictly linked to the right hemisphere lesions.
7. Statement of ethics
The study was carried out in compliance with the Helsinki Declaration and with the guidelines of the Ethical Committee of our
Institution. The patient has given her written informed consent.
8. Data availability statement
The authors confirm that the data supporting the findings of
this study are available within the article and/or its supplementary
materials.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jocn.2021.02.020.
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