Assessment of eye closure and blink with facial palsy: A systematic literature review

Impact of facial palsy impact on make-up habits: An observational cohort study

OBJECTIVE

The esthetic problems inherent to peripheral (PFP) are frequent causes of complaint. Make-up is advocated as a form of therapy and can alleviate symptoms of depression. The aim of the present study was to collect data on make-up habits in female PFP patients and assess links with esthetic and/or functional complaints.

MATERIAL AND METHODS

Two questionnaires were drawn up to compare make-up habits in female PFP patients and women in the general population. The first was sent out between September and December 2019, to 39 House-Brackmann grade III PFP patients (group A), and the second on-line questionnaire was sent to a control population of 1385 women (group B).

RESULTS

PFP patients used make-up more often than controls at weekends (χ2=16.38; P=0.0009) and while at home (χ2=8.21; P=0.042), and more often with foundation (χ2=17.21; P=0.0006) and lip make-up (χ2=59.31; P<0.0001). The greater their functional complaint, the less they made up their eyes. The greater their self-confidence and the more they felt attractive, the less they made up their lips.

CONCLUSION

The differences in make-up use found in the present study aimed to mask facial palsy and were related to the esthetic complaint, impacting social life.

Automated analysis of spontaneous eye blinking in patients with acute facial palsy or facial synkinesis

Although patients with facial palsy often complain of disturbed eye blinking which may lead to visual impairment, a blinking analysis is not part of routine grading of facial palsy. Twenty minutes of spontaneous eye blinking at rest of 30 patients with facial palsy (6 with acute palsy; 24 patients with facial synkinesis; median age: 58 years, 67% female), and 30 matched healthy probands (median age: 57 years; 67% female) was smart phone video recorded. A custom computer program automatically extracted eye measures and determined the eye closure rate (eye aspect ratio [EAR]), blink frequency, and blink duration. Facial Clinimetric Evaluation (FaCE), Facial Disability Index (FDI) were assessed as patient-reported outcome measures. The minimal EAR, i.e., minimal visible eye surface during blinking, was significantly higher on the paretic side in patients with acute facial palsy than in patients with synkinesis or in healthy controls. The blinking frequency on the affected side was significantly lower in both patient groups compared to healthy controls. Vice versa, blink duration was longer in both patient groups. There was no clear correlation between the blinking values and FaCE and FDI. Blinking parameters are easy to estimate automatically and add a functionally important parameter to facial grading.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

The effect of various muscle transfer procedures on eye closure and blinking in longstanding facial palsy patients

BACKGROUND

Facial palsy causes paralytic lagophthalmos, which remarkably deteriorates a patient's quality of life. In cases where denervation time is over 18-24 months (longstanding facial palsy), a free or pedicled muscle transfer is needed to replace the denervated orbicularis oculi muscle.

PURPOSE

The purpose of this systematic review is to investigate the effect of various eye sphincter substitution procedures (free or pedicled muscle transfers) in longstanding facial palsy patients on eye closure and blink.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the Embase, Medline, Web of Science and Cochrane Library databases and Google Scholar. Our literature search yielded 4322 articles. Following a full-text review, 4 retrospective cohort studies and 21 case series were selected for this review. Meta-analyses using R package meta (version 6.5-0) were conducted.

MAIN FINDINGS

All free and pedicled muscle transfers in this review showed an improvement in the scores and measurements on eye closure and blink. The pedicled temporalis muscle transfer was the procedure most commonly performed as eye reanimation surgery and showed consistent good results. Using the random effects model, the pooled effect of mean difference in lagophthalmos after gentle eye closure post-operatively versus pre-operatively (mm) in patients who received a pedicled (temporalis) muscle transfer was -6.19 (I2 = 85%, 95% CI: -7.89; -4.49) whereas it was -4.11 (I2 = 85%, 95% CI: -7.26; -0.95) for free (gracilis or platysma) muscle transfers. The pooled proportion of patients with complete eye closure after surgery was 0.69 (I2 = 49%, 95% CI: 0.54; 0.82) in patients who received a pedicled (temporalis) muscle transfer and 0.40 (I2 = 74%, 95% CI: 0.13; 0.74) in patients who received a free (platysma) muscle transfer.

CONCLUSIONS

Unlike smile reanimation, dynamic eye closure and blink restoration are rather neglected topics in facial reanimation. The pedicled temporalis muscle transfer is often recommended as the first treatment of choice for eye reanimation in longstanding facial palsy patients since it is a reliable, straightforward procedure, that does not require complex microsurgery. However, with the advancements in the field of microsurgery, free muscle transfers are promising therapies, which may regenerate voluntary and spontaneous blinking.

Dynamic eyelid reconstruction in facial nerve palsy

The consequences of facial nerve palsy and the secondary inability of eyelid closure and blink may lead to devastating complications for the patient, including blindness. Reconstruction techniques to improve eyelid position and function can be broadly classified into 'static' and 'dynamic' techniques. Generally, ophthalmologists have been familiar with static procedures such as upper eyelid loading, tarsorrhaphy, canthoplasty, and lower eyelid suspension. Recently, dynamic techniques are being increasingly described for patients who require definitive strategies to improve eyelid function, once the initial critical goals of corneal protection and vision preservation have been achieved. The choice of technique(s) is dependent upon the status of the main protractor of the eyelid region, as well as the age of the patient, the patient's morbidities and expectations, and surgeon preference. This review shall first describe the clinical and surgical anatomy relevant to the ophthalmic consequences of facial paralysis and discuss methods of defining function and outcomes. A comprehensive review of dynamic eyelid reconstruction is then presented with a discussion of the literature. These various techniques may not be familiar to all clinicians. It is important that ophthalmic surgeons are aware of all options available for their patients. Furthermore, eye care providers must have an understanding of when referral may be appropriate to provide timely intervention and optimal chances of recovery.

Agreement Between House-Brackmann and Sunnybrook Facial Nerve Grading Systems in Bell's Palsy in Children: Secondary Analysis of a Randomized, Placebo-Controlled Multicenter Trial

BACKGROUND

There is limited evidence on the use of facial nerve function grading scales in acute facial nerve paralysis in children.

OBJECTIVE

To investigate the agreement between and the usability of the House-Brackmann and Sunnybrook scales in children with idiopathic facial paralysis (Bell's palsy) and to compare their ease of administration.

METHODS

Data from a randomized controlled trial in children aged 6 months to <18 years with Bell's palsy was used. Children were recruited within 72 hours of symptom onset and assessed using the House-Brackmann and the Sunnybrook scales at baseline and at 1, 3, and 6 months until recovered. Agreement between the scales was assessed using the intraclass correlation coefficient (ICC) at each time point and using a Bland-Altman plot. Ease of administration was assessed using an 11-point Likert scale.

RESULTS

Comparative data were available for 169 of the 187 children randomized. The ICC between the 2 scales across all time points was 0.92 (95% confidence interval [CI] 0.91-0.93), at baseline 0.37 (95% 0.25, 0.51), at 1 month 0.91 (95% CI 0.89-0.94), at 3 months 0.85 (95% CI 0.80-0.89), and at 6 months 0.96 (95% CI 0.95-0.97). The median score for the ease of administration for the House-Brackmann and Sunnybrook scales was 3 (interquartile range [IQR]: 1-5) and 7 (IQR: 4-8) respectively (P < .001, Wilcoxon signed-rank test).

CONCLUSIONS

There was excellent agreement between House-Brackmann and Sunnybrook scales, with poorer agreement at baseline. Clinicians found the House-Brackmann scale easier to administer. These findings suggest that both scales can be applied in children.

Modified blink dynamic index predicts activity and severity in patient with facial nerve palsy

Purpose

We analyzed the dynamics of blink and defined the blink index in facial nerve palsy (FNP) patients using an ocular surface interferometer associated with clinical characteristics and clinical progress.

Methods

In total, 49 patients were enrolled this study. All patients were tested using an ocular surface interferometer which is used to measure blink patterns (total blink (TB), partial blink rate (PBR)) and blink dynamics (blink time (BT), lid closing time (LCT), closure time (CT), lid opening time (LOT), interblink time (IBT), closing speed (CS), and opening speed (OS)) using 600 frames recorded over 20 s. The distance of lagophthalmos and modified interpalpebral fissure (IPF), which was defined as the actual moving distance of the upper eyelid, subtracting the distance of lagophthalmos from IPF, was measured using the ImageJ program. The types of FNP were "idiopathic" (Bell's palsy) and "surgical" (following the neurosurgery). Patients were classified into "acute" and "chronic" based on the duration of 6 months from the onset time of FNP. The clinical characteristics were classified into mild or severe according to the severe degree of exposure keratopathy-as "severe" if treatment such as tarsorrhaphy and gold plate insertion was required.

Results

Reduced MRD1, brow height, and modified IPF and increased lagophthalmos were noted in the palsy side. LCT was longer and CS, modified CS, and modified OS were shorter in the palsy side. The LCT was longer and the modified CS was shorter in idiopathic patients with acute onset and with clinically severe. IBT was increased in idiopathic patients with clinically severe.

Conclusion

Analyzing the blink patterns and blink dynamics, this study suggests meaningful indicators among blink profiles and dynamics, LCT, and modified CS based on modified IPF. It was more associated in the idiopathic type than in the surgical type of FNP patients. The modified CS can be a useful tool for evaluating the activity and severity indicator of FNP.

Facial nerve palsy: Narrative review on the importance of the eye and its assessment

New solutions are emerging that address specific facial regions in facial nerve palsy (FNP). However the most dreaded consequence of FNP is paralytic lagophthalmos threatening the eye. A way to prioritize these regions is thus required. A review of the literature is conduced to capture the current concepts in evaluating FNP. Overall, patients are assessed from three perspectives: from the clinician's perspective using validated clinician-based grading instruments, from patient's perspective based on FNP-specific patient-reported outcome measures, and from the perspective of the layperson. The existing tools however provide limited information regarding the relative importance of different regions of the face. The eye appears to be an area of great concern for the patient where most surgical therapies are directed at. Addressing ocular problems in FNP carry a high priority but this is not clearly reflected by the standard systems.