Oculoplastic surgical treatment in the management of the patient with a facial palsy has a number of indications and aims:
- The prevention or management of corneal exposure
- The correction of lower eyelid ectropion
- The management of brow ptosis
- The management of chronic epiphora (watering eye)
A number of other disciplines may be involved in the care of the patient with a facial palsy, e.g. an ENT (ear, nose and throat) surgeon, a neurosurgeon, a neurologist, a plastic surgeon, a physician. It is essential that effective communication exist between such clinicians for the optimal care of the patient. The ophthalmologist must be made aware of the prognosis for recovery of facial nerve function, e.g. following the removal of an acoustic neuroma, and of any plans for surgery by other colleagues, e.g. facial reanimation surgery.
The primary goal is to protect the cornea (the clear “window” at the front of the eye). Sight threatening complications of a facial palsy relate to a condition called corneal exposure (exposure keratopathy) in which the front of the eye, normally lubricated and protected by blinking of the eyelids, can become dry, ulcerated and scarred when the eyelids are unable to close.
The problems of exposure of the cornea are even more serious in those patients who have lost corneal sensation from the eyeball. Such patients are unaware when the eye is dry, ulcerated or has sustained any damage from simple rubbing of the eye, or during sleep if the eyelids are not fully closed. Often a red eye in these situations will alert the patient to corneal exposure. If the eye becomes red then you should consult your surgeon as soon as possible.
A number of relatively simple medical therapies can be applied, particularly for a limited time in the patient who has a good prognosis for the recovery of facial nerve function and who has no risk factors for the development of exposure keratopathy.
- The use of frequent preservative free topical lubricants
- The avoidance of ocular irritants
- The use of spectacle side shields or moisture chamber goggles
- Taping the eye closed at night
- Upper eyelid botulinum toxin injections
- The application of external eyelid weights
The most common ophthalmic treatment for facial palsy is the use of frequent lubricants. The lubricants should be used at least on an hourly basis during the day and should be preservative free to avoid corneal toxicity from such frequent exposure to preservatives. The use of preservative free lubricant ointment e.g. Lacrilube, provides more efficient corneal protection than drops with a much reduced frequency of instillation but with more blurring of vision. Patients should avoid ocular irritants wherever possible, e.g. tobacco smoke.
Most patients do not tolerate moisture chamber goggles or plastic wrap occlusive dressings but spectacle side shields are relatively unobtrusive and well tolerated.
The upper eyelid can be taped closed over the eye at night using Micropore tape but it is essential to ensure that the eye is fully closed to prevent further trauma to the cornea by the tape.
Botulinum toxin can be injected into the levator muscle to induce a ptosis for a patient with a temporary facial palsy (Figure 7.7). This is, however, expensive and commits the patient to monovision for a period of 8–12 weeks before spontaneous recovery occurs. Some patients can develop problems with fusion and suffer diplopia following the use of botulinum toxin. In addition, as the superior rectus can be weakened, the Bell’s phenomenon may be adversely affected, creating more problems with exposure keratopathy during the recovery phase.
An external eyelid weight may be applied to the upper eyelid with a tissue adhesive. The weight is flesh coloured to make it less conspicuous. Such weights are useful for a temporary facial palsy but can also be used for a trial period before subjecting a patient to an upper eyelid gold weight implant.
In patients with decreased tear production who cannot be managed adequately with topical lubricants alone, punctal occlusion is beneficial. This can be achieved temporarily with the use of silicone punctal plugs. If these are tolerated without secondary epiphora, surgical punctal occlusion can be performed under local anaesthesia.
Temporary suture tarsorrhaphy
A temporary suture tarsorrhapy can be used for the patient who has an acute facial palsy and who is unsuitable to undergo any other procedure or who is unable to instill lubricant drops or ointment e.g. the patient who has undergone major neurosurgery and who will be in a bed in intensive care for a few days. A 4.0 nylon suture is passed through the grey line of the upper and lower eyelids and tied over silicone or rubber bolsters .The suture can be tied with a slipknot enabling the tarsorrhapy to be opened to examine the eye.
A lateral tarsorrhaphy has been the time-honoured simple surgical method of providing adequate corneal protection in the management of the patient with a facial palsy. This involves the stitching together of the outer aspects of the eyelids which then heal together. The procedure is reversible.
In this procedure the eyelids medial to the puncta (the inner aspect of the eyelids) are fused. This procedure is often used in addition to a lateral tarsorrhaphy to further improve corneal protection in a patient with a facial palsy. It also helps to prevent the development of a medial lower lid ectropion.
Müllerectomy and levator aponeurosis recession
A removal of Müller’s muscle and a gentle recession of the upper eyelid retractors may benefit the patient with a chronic facial palsy with upper eyelid retraction, to reduce the area of the cornea that is exposed.
Gold (or platinum) weight insertion
Gold (or platinum) weight implantation is a simple and useful procedure for the patient with a chronic facial palsy. It is particularly useful in the patient who has had a lateral tarsorrhaphy performed and is dissatisfied with the cosmetic appearance, and wishes for the procedure to be reversed. The success of gold (or platinum) weight implantation depends on careful patient selection. The procedure improves eyelid closure but it does not restore a normal reflex blink.
The correction of lower eyelid ectropion
The management of greater degrees of ectropion in a patient with a facial palsy depends on an evaluation of the causes of the ectropion, e.g. chronic overflow tearing may lead to cicatricial (scarring) changes that may require a skin graft procedure.
In patients who are poor candidates for a facial reanimation procedure by a specialist plastic surgeon, the mid-face ptosis may be addressed either with a static sling using autogenous fascia lata to pull the lip and face upward toward the zygomatic arch, or with a sub-orbicularis oculi fat (SOOF) or mid-face lift. These procedures help to eliminate the inferior traction of the sagging face from the lower eyelid.
The correction of chronic watering of the eye
In spite of the successful correction of a lower eyelid ectropion, and the improvement of eyelid closure and exposure keratopathy, the patient may still experience chronic watering of the eye due to a poor lacrimal pump mechanism. In such cases it may be necessary to resort to an endoscopic conjunctivo-dacryocystorhinostomy (CDCR) with placement of a Lester Jones tube.
The management of brow ptosis
A unilateral brow ptosis may be severe enough to cause impairment of the superior visual field as well as a cosmetic deformity (Figure 7.25). It can cause a pseudo-blepharoptosis (an apparent but not true droop of the upper eyelid), and may lead to a secondary misdirection of the upper eyelid lashes which can irritate the eye.
Although a number of different surgical approaches for the management of a brow ptosis complicating a facial palsy have been described, the preferred approaches are:
- A direct brow lift
- An endoscopic brow lift
A direct brow lift
A direct brow lift is a simple but effective procedure to correct a unilateral brow ptosis. It can be combined, if necessary, with an upper eyelid blepharoplasty. If a blepharoplasty is deemed to be necessary, the brow lift should be performed first. The blepharoplasty should be very conservative to avoid aggravating any incomplete eyelid closure.
Endoscopic brow lift
An endoscopic brow lift in the management of a unilateral brow ptosis avoids visible scars but is less likely to provide a long lasting result.
Aberrant reinnervation of the facial nerve
Aberrant reinnervation can occur following recovery from a facial palsy. The degree of disability from aberrant reinnervation is variable. Some patients experience complete eyelid closure when using the perioral (mouth) muscles. Such patients may be treated with botulinum toxin injections to the orbicularis oculi muscles (the eyelid muscle responsible for reflex and voluntary eyelid closure), but such treatment can worsen incomplete eyelid closure and increase the need for frequent topical lubricants.
Direct neurotization of the cornea using the contralateral supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve is a procedure that may restore some corneal sensation to selected patients with a unilateral facial palsy and an anesthetic cornea.
After surgery, depending on the surgical procedure which has been undertaken, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelid/brow wounds very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
The upper lid scars gradually fade to fine white marks within a few months. The scars are usually hidden within the skin crease .
You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops if you have any allergies. These will be prescribed for you e.g. Hyabak drops, Hylotears, Hylotears Forte, Systane eye drops preservative free, Viscotears preservative free, Liquifilm tears preservative free, or Celluvisc drops and Lacrilube ointment, VitaPos ointment or Artelac night time gel at bedtime.
It is often recommended that you use Lacrilube ointment to the eyes 1-2 hourly for the first 48 hours after surgery following any upper lid surgery but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). These medications can be purchased from Face & Eye or online from the clinic’s online shop (www.faceandeyeshop.co.uk).
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.