Effectiveness of the gold weight trial procedure in predicting the ideal weight for lid loading in facial palsy: a prospective study

[Clinical and morphological aspects of the use of palpebral implants made of noble metals]

Loading of the upper eyelid with palpebral implants made of noble metals is the modern standard of surgical treatment for paralytic lagophthalmos, and is aimed at increasing the mobility of the upper eyelid and normalizing involuntary blinking movements. This review presents the results of morphological studies, including immunohistochemical studies, reflecting the features of biointegration of palpebral implants in uncomplicated and complicated course of the postoperative period, and describes the modern understanding of the causes and immunopathological processes underlying the development of nonspecific inflammatory response, which is one of the most serious complications that often becomes an indication for implant removal.

Modified tarsorrhaphy versus gold weight implant technique for paralytic lagophthalmos treatment in patients with leprosy: One-year observation of a randomized controlled trial study

Trial design

This study was a multicenter, Prospective Randomized Open-label Blinded-Endpoint (PROBE) clinical trial, parallel-group study conducted in Indonesia (three sites).

Methods

The aim of this study was to compare the effectivity and efficiency of modified tarsorrhaphy (MT) and gold weight implant (GWI) techniques in the surgical treatment of paralytic lagophthalmos in patients with leprosy. The study sample consisted of 23 eyes, with 11 eyes in the MT group and the remaining 12 eyes in the GWI group-the control group.

Results

The central eyelid margin distance (lagophthalmos distance) decreased when gentle pressure was applied in the MT (3.09 mm to 0.43 mm) and GWI groups (3.21 mm to 0.83 mm) at postoperative year 1. The Ocular Surface Disease Index score, the tear break-up time, and the Schirmer test without and with anesthesia in the MT and GWI groups showed a p-value of > 0.05. Epitheliopathy improvement occurred in 54.55% of the MT group and 58.33% of the GWI group. Corneal sensitivity change in the inferior quadrant of the MT group (50.00 to 51.30 mm) and in the GWI group (49.61 to 52.93 mm) resulted in a p > 0.05. Postoperative complications occurred in 15% of patients in the GWI group. In addition, the surgery duration of both techniques was similar. Furthermore, the surgery cost in the MT and GWI groups yielded a p < 0.05.

Conclusion

The MT technique is as effective as the GWI technique but more efficient than the GWI technique as a surgical treatment for paralytic lagophthalmos in patients with leprosy.

Clinical trial registration

[www.ClinicalTrials.gov], identifier [NCT0494 4498].

The impact of implantation site on procedure success in patients with unresolved facial palsy treated with upper-eyelid gold weight loading

Loading of the upper eyelid is a well-established procedure for the correction of incomplete eyelid closure due to unresolved facial palsy. Some incurable complications are attributed to type IV hypersensivity reaction, but there is no confirmation of this hypothesis. The aim of the study was to show the impact of gold weights on eyelid tissues depending on the implantation site. Out of 94 total patients (aged 53 ± 17 years) treated from July 2009-2021, since 2014 thirty consecutive patients were randomised into one of 3 groups: the GLE group (gold weight fixed 2 mm above the eyelash line), the GUE group (gold weight fixed at the border of the tarsus and the levator aponeurosis), and the PUE group (platinum chain fixed in the same way as in the GUE group). In the cases of complications, the explanted weights were evaluated histopathologically. The outcomes were compared between groups. Incomplete eyelid closure was corrected in all patients. Serious complications were noted in 100% of patients in the GLE group and 20% in the GUE group (p < 0.0001). A slight lymphocytic reaction was observed in the GUE group. A moderate to significant lymphocytic reaction was observed in the GLE group (p < 0.001). Adverse reactions of the upper eyelid microenvironment resulting from gold weights seem to be dependent on mechanical damage to the eyelid structures, rather than on implants themselves. The site of placement of the weight in the upper eyelid may be critical for procedure success.

Efficacy and safety of platinum chain and gold weight implants for paralytic lagophthalmos: a systematic review

BACKGROUND Surgery has been proposed as a treatment of paralytic lagophthalmos. However, no consensus has been reached on the best treatment. This study was aimed to investigate the efficacy and safety between platinum chain and gold weight implants to treat paralytic lagophthalmos. METHODS This study used all randomized controlled trials or observational studies (prospective or retrospective) using platinum chain and gold weight implants for paralytic lagophthalmos surgery that were published from 1990 to 2020 in the PubMed, Cochrane, and Google Scholar databases. Efficacy was indicated by the reduction of ≥3 in lagophthalmos, and safety was measured based on complications after surgery. RESULTS The efficacy of platinum chain and gold weight implants were 60–100% and 10–93.6%, respectively. The complications of platinum chain implant were 0–2.9% of extrusion and 0–3.3% of migration. However, gold weight implant had 0–13.3% of migration. CONCLUSIONS Both platinum chain and gold weight implants have similar efficacy to treat paralytic lagophthalmos. However, gold weight implant has a higher rate of complication.

Update on the ophthalmic management of facial paralysis

Bell's palsy is the most common neurologic condition affecting the cranial nerves. Lagophthalmos, exposure keratopathy, and corneal ulceration are potential complications. In this review, we evaluate various causes of facial paralysis as well as the level 1 evidence supporting the use of a short course of oral steroids for idiopathic Bell's palsy to improve functional outcomes. Various surgical and nonsurgical techniques are also discussed for the management of residual facial dysfunction.

Rehabilitation of Eyelid Malpositions Secondary to Facial Palsy

Objectives:

To evaluate patient satisfaction and outcomes of surgical treatment of eyelid malpositions secondary to facial palsy.

Materials and Methods:

Consecutive patients with facial palsy who underwent surgical treatment by the same surgeon at İzmir Katip Çelebi University Atatürk Training and Research Hospital between Jan 2007 and Dec 2012 were included in the study. Ophthalmic examination findings, surgical approaches, and their outcomes were evaluated. A successful result for upper eyelid position was defined as more than 50% reduction in lagophthalmos and induction of less than 2 mm of ptosis. A successful outcome for lower eyelid position was defined as the lower eyelid residing at or within 1 mm above or below the limbus. Linear visual analog scale 1 (VAS-1) (subjective complaints) and VAS-2 (cosmetic outcome), both ranging from 0 to 10, were used to compare preoperative findings with findings at last postoperative visit.

Results:

The mean age of the 14 female and 21 male patients was 54.5±19.9 years. Gold weight implantation (n=31), lateral tarsal strip (n=22), tarsorrhaphy (n=15), suborbicularis oculi fat elevation (n=16), hard palate graft (n=14), and eyebrow ptosis repair (n=6) were performed. Average follow-up time was 17.9±16.9 months (range, 2-60). Surgical success rates were 90% for upper lids and 75% for lower lids. Mean lagophthalmos decreased from 7.1±2.7 mm to 1.6±1.6 mm postoperatively (p=0.000). The use of lubricating drops and gels was reduced from average preoperative daily values of 5.3±2.5 drops and 1.3±0.6 gel applications to 4.4±1.4 and 0.6±0.6, respectively (p=0.003, p=0.001).

Conclusion:

An individualized surgical approach tailored according to each patient’s severity of facial palsy and associated malpositions resulted in both functional and aesthetic improvements in our patients.

[Gold weight implants for lagophthalmos correction in chronic facial nerve paralysis (late results)]

Upper eyelid weigh gold implant is the widely accepted standard for the treatment of paralytic lagophthalmos (PL).

AIM

To evaluate late outcomes of PL correction with chain gold implants.

MATERIAL AND METHODS

Chain gold implants were inserted in the upper eyelids of 70 patients with lagophthalmos due to chronic facial paralysis. A comprehensive ophthalmic examination was performed prior to surgery and then at months 1, 3, 6, 12, 24, and 36.

RESULTS

The results obtained prove the method highly effective. None of the patients developed any severe complications. Cases of implant removal were few. Some of the studied biometric parameters decreased significantly after surgery, while the upper eyelid excursion increased. The implant had no effect on the inner surface of the cornea and its peripheral thickness.

CONCLUSION

Efficacy of the proposed eyelid implant has been convincingly demonstrated; late complications have been analyzed.

Spontaneous Blinking Kinetics on Paralytic Lagophthalmos After Lid Load with Gold Weight or Autogenous Temporalis Fascia Sling

PURPOSE

To assess the upper eyelid kinematics during spontaneous blinking in unilateral paralytic lagophthalmos before and after upper eyelid load with gold weight (GW) or autogenous temporalis fascia (TF) sling.

DESIGN

Comparative case series.

SUBJECTS

Patients with long-standing unresolved unilateral facial palsy who underwent surgical treatment with GW (n = 8) or upper lid cerclage with TF (n = 10). The contralateral eyelid served as the control for each patient (control group).

METHODS

Preoperative and postoperative measurements of spontaneous blink kinematics with magnetic search coil and clinical assessment of lid margin position, lagophthalmos and ocular surface exposure, and determine amplitude, maximum velocity and main sequence of spontaneous blinks; relative amplitude of blinks to the pupil center; ocular surface exposure scores; magnitude of lagophthalmos and mid-pupil lid distances.

RESULTS

The mean (±SE) down-phase amplitude ratio between paralyzed and contralateral eyelids (blink gain) was 10.0% preoperatively for both groups and significantly increased to 29 ± 6% for the GW group (p < 0.05) and 23 ± 4% for the TF group (p < 0.05). At 6 months the gain was significant for the GW group only (32 ± 7%, p < 0.05). There was no effect on the maximum velocity of the blinks or the main sequence of paretic and contralateral blinks with either surgery. Both procedures lowered the lid margin increasing the number of blinks that reached the pupil center. At 6 months this effect was prominent only for the GW group. Exposure keratopathy scores and lagophthalmos decreased postoperatively especially in the GW group.

CONCLUSIONS

The beneficial effect of lid load surgeries result from a combination of a small increase on the spontaneous blink amplitude and a static effect due to the reduction of the distance between the lid margin and pupil center.

[Correction of paralytic lagophthalmos]

Current options for correction of paralytic lagophthalmos are either temporary (external eyelid weight placement, hyaluronic acid gel or botulinum toxin A injection) or permanent (various procedures for narrowing of the palpebral fissure, upper eyelid weights or spring implantation). Neuroplastic surgery (cross-facial nerve grafting, nerve anastomoses) and muscle transposition surgery is not effective enough. The majority of elderly and medically compromised patients should not be considered for such complicated and long procedures. Upper eyelid weight implantation thus appears the most reliable and simple treatment.

Neuro-ophthalmological approach to facial nerve palsy

Facial nerve palsy is associated with significant morbidity and can have different etiologies. The most common causes are Bell's palsy, Ramsay-Hunt syndrome and trauma, including surgical trauma. Incidence varies between 17 and 35 cases per 100,000. Initial evaluation should include accurate clinical history, followed by a comprehensive investigation of the head and neck, including ophthalmological, otological, oral and neurological examination, to exclude secondary causes. Routine laboratory testing and diagnostic imaging is not indicated in patients with new-onset Bell's palsy, but should be performed in patients with risk factors, atypical cases or in any case without resolution within 4 months. Many factors are involved in determining the appropriate treatment of these patients: the underlying cause, expected duration of nerve dysfunction, anatomical manifestations, severity of symptoms and objective clinical findings. Systemic steroids should be offered to patients with new-onset Bell's palsy to increase the chance of facial nerve recovery and reduce synkinesis. Ophthalmologists play a pivotal role in the multidisciplinary team involved in the evaluation and rehabilitation of these patients. In the acute phase, the main priority should be to ensure adequate corneal protection. Treatment depends on the degree of nerve lesion and on the risk of the corneal damage based on the amount of lagophthalmos, the quality of Bell's phenomenon, the presence or absence of corneal sensitivity and the degree of lid retraction. The main therapy is intensive lubrication. Other treatments include: taping the eyelid overnight, botulinum toxin injection, tarsorrhaphy, eyelid weight implants, scleral contact lenses and palpebral spring. Once the cornea is protected, longer term planning for eyelid and facial rehabilitation may take place. Spontaneous complete recovery of Bell's palsy occurs in up to 70% of cases. Long-term complications include aberrant regeneration with synkinesis. FNP after acoustic neuroma surgery remains the most common indication for FN rehabilitation.

Lid loading for treatment of paralytic lagophthalmos

Lagophthalmos secondary to facial palsy is a most clinically important condition that requires effective and early treatment because prolonged corneal exposure may cause corneal lesions, ranging from corneal spots to corneal ulceration and finally blindness. Lid loading is the therapy used most commonly to treat the condition. This method was first described in 1950, modified in 1966, and popularized in 1974. Since its inception, only several reviews have referred to the technology, but they talked about only parts of this technology and did not provide information on the technology overall. This review discusses lid loading in detail. This method now often uses gold and platinum as the material for the implant and should be done as early as possible in those patients whose paralytic lagophthalmos has little chance of being reversed. This method has shown good clinical results and given patients a better perspective. Of course, this method has its intrinsic complications such as allergic reactions, extrusion, and migration. However, with modification of the implant and the surgical procedure, the complication rate has decreased. In conclusion, although lid loading cannot solve all the problems associated with the paralyzed eyelid, it is a simple, reversible, and effective way to treat paralytic lagophthalmos.