Bilateral ictal eye closure in focal epileptic seizures: SEEG retrospective observational assessment from a tertiary epilepsy center

Ictal eye closure is commonly associated with functional seizures but may also occur in epileptic seizures. We retrospectively reviewed 113 consecutive stereo-EEG (SEEG) recordings from adults with drug-resistant focal epilepsy (2015-2024) to identify prolonged bilateral eye closure during seizures. Nine individuals exhibited this through 17 seizures; eight seizures arose from sleep. Inter-rater reliability was good (ICC = 0.72). The median age was 35 years, and the epilepsy duration was 25 years. Eye closure started mainly at EEG onset and persisted for approximately 50% of the seizure. Consciousness was impaired in seven seizures and preserved in three. Presumed epileptogenic zones were unilateral in eight people and uncertain in one, involving various cortical and subcortical areas. Seven of them were offered surgical resection or laser interstitial thermal therapy (LITT). Ictal eye closure showed no clear localizing or lateralizing value, likely due to widespread network involvement. It may reflect disruption of sensory, executive, or arousal systems. SEEG spatial sampling limitations could have affected the detection of involved areas. Further prospective studies are needed to clarify its clinical significance.