Management of the Eye in Facial Paralysis

Lateral Tarsal Strip versus Tensor Fascia Lata Sling for Paralytic Ectropion: Comparison and Long-Term Outcomes

BACKGROUND

Paralytic ectropion increases risk for corneal injury in facial palsy patients. Although a lateral tarsal strip (LTS) provides corneal coverage through superolateral lower eyelid pull, the unopposed lateral force may result in lateral displacement of the lower eyelid punctum and overall worsening asymmetry. A tensor fascia lata (TFL) lower eyelid sling may overcome some of these limitations. This study quantitatively compares scleral show, punctum deviation, lower marginal reflex distance, and periorbital symmetry between the two techniques.

METHODS

Retrospective review was performed on facial paralysis patients who underwent LTS or TFL sling surgery with no prior lower lid suspension procedures. Standardized preoperative and postoperative images in primary gaze position were used to measure scleral show and lower punctum deviation using ImageJ, and lower marginal reflex distance using Emotrics.

RESULTS

Of 449 facial paralysis patients, 79 met inclusion criteria. Fifty-seven underwent LTS surgery and 22 underwent TFL sling surgery. Compared with preoperatively, lower medial scleral show improved significantly with both LTS (10.9 mm 2 ; P < 0.01) and TFL (14.7 mm 2 ; P < 0.01). The LTS group showed significant worsening of horizontal and vertical lower punctum deviation when compared with the TFL group (both P < 0.01). The LTS group was unable to achieve periorbital symmetry between the healthy and paralytic eye across all parameters measured postoperatively ( P < 0.01); and the TFL group achieved symmetry in medial scleral show, lateral scleral show, and lower punctum deviation.

CONCLUSION

In patients with paralytic ectropion, TFL sling provides similar outcomes to LTS, with the added advantages of symmetry without lateralization or caudalization of the lower medial punctum.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Upper eyelid weighting for lagophthalmos results in contralateral upper eyelid elevation

INTRODUCTION

Upper eyelid weighting decreases lagophthalmos by improving blink dynamics. The effect of weighting on static eyelid position is less well understood. This study describes the effect of upper eyelid weighting on ipsilateral and contralateral upper eyelid position.

METHODS

Patients with unilateral lagophthalmos who underwent upper eyelid weight implantation were included. Primary outcome measures were ipsilateral and contralateral margin to reflex distance 1 (MRD1), preoperatively and postoperatively. MRD1 symmetry was assessed as a secondary outcome measure. Weight mass was examined as a covariate of MRD1 change.

RESULTS

23 patients (16 female, 7 male) met inclusion criteria. After weighting, contralateral MRD1 increased from mean [SD] 2.91 [1.41] mm to 3.77 [1.75] mm (p < .05). Ipsilateral (weighted) MRD1 did not significantly change (2.64 [1.41] mm to 2.40 [1.18] mm, p = .11). Preoperatively, paretic and normal side MRD1 were not different (p = .52). Postoperatively, weighted and unweighted MRD1 were significantly different (p < .05). Weight mass was not a covariate of MRD1 change, neither ipsilateral nor contralateral (p = .76, p = .71, respectively). The proportion of patients with MRD1 asymmetry ≥ 1 mm preoperatively (12/23, 52.2%) did not change following surgery (17/23, 73.9%, p = .12).

CONCLUSION

Weight insertion led to contralateral eyelid elevation, a manifestation of Hering's law. Weight mass did not impact the magnitude of MRD1 change, and the proportion of patients with MRD1 asymmetry ≥ 1 mm did not change following surgery. These findings may guide surgeons in their preoperative planning and in counseling of patients.

Eye Sphincter Reanimation in Facial Paralysis: Evaluation, Indications, Techniques, and Outcomes

ABSTRACT

Facial nerve paralysis (FNP) sequela includes dysregulation of the ocular surface protective mechanism, nasolacrimal system pump failure and punctal eversion causing chronic epiphora, foreign body sensation, corneal injury, and, in the most severe cases, visual loss, particularly in the presence of comorbid corneal hypesthesia. Concerns over the ocular surface protection in FNP patients have led to the development of numerous static and dynamic procedures. While initial assessment of the FNP patients is complex and requires a comprehensive understanding of the blink reflex physiology, clinical evaluation and the use of additional work should be directed toward potential eye sphincter reanimation using a multidisciplinary approach. As with any treatment algorithm, numerous factors must be considered to provide an individualized treatment plan. In the case of FNP, it is important to consider denervation time, patient age, cause of paralysis, and neurologic severity of the paralysis. The aim of this article is to provide a thorough review of the physiology of the blink reflex, evaluation of the eye sphincter mechanism in FNP, and a comprehensive treatment algorithm incorporating static and dynamic procedures, along with a historical perspective.

Pillar tarsoconjunctival flap: An alternative approach for the management of refractory corneal ulcer

PURPOSE

To report the effectiveness of the surgical procedure of the tarsoconjunctival flap (FTC) in patients with severe ocular surface impairment refractory to previous conventional treatments.

METHODS

A retrospective, noncomparative, consecutive case series.

RESULTS

Pillar tarsoconjunctival flap (PTCF) was performed in eight eyes of eight patients. Three patients had neurotrophic corneal ulcer (NCU), three had exposure keratopathy and two had corneal melting. Seven of them had satisfactory postoperative results, showing total corneal re-epithelialization that lasted throughout the postoperative follow-up (mean 10.33 ± 2.65 months [SD], range 6 to 12 months). Mean time for the re-epithelization was 11.28 ± 8.97 days [SD] (range 4 to 30 days).

CONCLUSION

This study suggest PTCF is a valid alternative to tarsorrhaphy in cases of persistent epithelial defect (PED) or NCU resistant to conventional treatments. Notwithstanding, prospective comparative trials comparing PTFC with conventional and/or novel therapies in PED or NCU are needed to corroborate these findings.

Neuro-Ophthalmic Complications of Vestibular Schwannoma Resection: Current Perspectives

Vestibular schwannomas (VSs), also called acoustic neuromas, are benign intracranial neoplasms of the vestibulocochlear (VIII) cranial nerve. Management options include “wait-and-scan,” stereotactic radiosurgery and surgical resection. Due to the proximity of the VIII nerve to the facial (VII) nerve in the cerebello-pontine angle, the VII nerve is particularly vulnerable to the effects of surgical resection. This can result in poor eye closure, lagophthalmos and resultant corneal exposure post VS resection. Additionally, compression from the tumor or resection can cause trigeminal (V) nerve damage and a desensate cornea. The combination of an exposed and desensate cornea puts the eye at risk of serious ocular complications including persistent epithelial defects, corneal ulceration, corneal vascularization, corneal melting and potential perforation. The abducens (VI) nerve can be affected by a large intracranial VS causing raised intracranial pressure (a false localizing sign) or as a result of damage to the VI nerve at the time of resection. Other types of neurogenic strabismus are rare and typically transient. Contralaterally beating nystagmus as a consequence of vestibular dysfunction is common post-operatively. This generally settles to pre-operative levels as central compensation occurs. Ipsilaterally beating nystagmus post-operatively should prompt investigation for post-operative cerebrovascular complications. Papilledema (and subsequent optic atrophy) can occur as a result of a large VS causing raised intracranial pressure. Where papilledema follows surgical resection of a VS, it can indicate that cerebral venous sinus thrombosis has occurred. Poor visual function following VS resection can result as a combination of all these potential complications and is more likely with larger tumors.

[Dynamic procedures for facial nerve reconstruction]

In this article the indications and surgical treatment options for patients with facial nerve palsy are discussed. A distinction is made between static and dynamic surgical procedures. Static reconstructions for example are used to restore the eyelid closure function. For smile reconstruction, which is important for the psychosocial life of the patient, dynamic procedures are used. Depending on the duration of the facial nerve paralysis, there are several possibilities to restore the smile. In this work the masseteric branch transposition to the buccal branch, the hypoglossal-facial nerve anastomosis, the Labbé procedure and the gracilis flap as a free muscle transplant are discussed. The surgical procedures are compared and the advantages and disadvantages of the intervention are presented. A spontaneous smile is aimed, this cannot always be achieved. With the masseteric branch transposition to the buccal branch and the Labbé procedure the smile is initially triggered by chewing. A spontaneous smile is possible through cortical adaptation. With the gracilis flap, however, a nerve anastomosis with the contralateral 'healthy' facial nerve is possible, either directly or via a so-called cross facial nerve grafting, whereby a spontaneous smile can be achieved.

Probability assessment of facial nerve injury in children and adolescents during the elective maxillofacial surgery

Relevance. Various factors can cause facial neuropathy. Iatrogenic facial nerve injury in childhood and adolescence is a complicated medical, psychological and legal problem. Risk assessment of the facial nerve injury during the elective maxillofacial surgeries is required depending on the localization of the procedure. The statistical assessment is very important for the evaluation of the possible iatrogenic facial neuropathy in children and adolescents during the elective maxillofacial surgeries.Materials and methods. 715 medical records for 2017 from the Department of Pediatric Maxillofacial Surgery of the MSUMD Clinical Center for Maxillofacial, Reconstructive and Plastic Surgery were analyzed.Results. There was a risk of injury to the trunk or branches of the facial nerve during surgery in 121 cases (16,9%) for the technical complexity of the surgical approach and the pathology location.Conclusions. There is a high risk of the facial nerve injury during the elective maxillofacial surgery in children and adolescents due to the complex anatomy of the area. Intraoperative neuromonitoring is recommended to prevent iatrogenic neuropathy of the facial nerve.

Role of the neurotologist in posterior fossa meningioma surgery

Posterior fossa meningiomas that impinge on structures of the temporal bone or clivus may be difficult to access for optimal resection that maximizes tumor control and minimizes short- and long-term morbidities. To address this challenge, the contemporary neurosurgery-neurotology team works collaboratively by managing patients jointly at every stage of care: preoperative evaluation, intraoperative intervention, and postoperative treatment. The neurotologist is important at all stages of posterior fossa meningioma surgery. First, detailed preoperative evaluation of auditory, facial, vestibular, and lower cranial nerve integrity enables assessment of new neurologic deficit risk, prognosis of functional recovery, and pros and cons of candidate surgical approaches. Second, intraoperative partitioning of surgical steps by provider and adopting an overlapping tumor resection philosophy creates an efficient and confident surgical team built on trust. Third, postoperative closure of cerebrospinal fluid leak and treatment of facial weakness, audiovestibular dysfunction, and voicing and swallowing impairments organized by the neurotologist reduces the impact of negative outcomes. The role of the neurotologist in posterior fossa meningioma surgery is to deliver nuanced evaluative metrics, facilitate shared decision making, perform precise bone and soft tissue microsurgery, and mitigate perioperative morbidities.

Considerations in Orbital Reconstruction for the Oncologic Surgeon: Critical versus Optimal Objectives

Background Orbital reconstruction following oncologic midface resection is uniquely challenging, and makes critical contributions to patient aesthetics, function, and identity. Approach is largely dependent on surgeon and patient preferences, and there exists no consensus on defect characterization. Objective The goal of the study is to provide a mental framework for the reconstructive oncologic surgeon to use as a foundation during his or her approach to the orbit. Design The design of the study is based on the review of current literature and expert opinion. Conclusions Critical versus optimal objectives must be set in orbital reconstruction, and a systematic approach should be followed. We approach orbital reconstruction by first deciding whether globe-sparing surgery is possible, or if orbital exenteration will be necessary. We then set critical and optimal objectives for our chosen pathway. Critical goals in globe-sparing reconstruction include maintaining orbital volume and preserving visual function, and an optimal goal includes preservation of the nasolacrimal system. Critical goals in orbital exenteration include obliterating the defect, sealing the skull base and nasal cavities, and allowing eye protection to be worn over the contralateral eye postoperatively. Optimal goals in exenteration include preparation for prosthetics, volume and bony replacement, eyelid-sparing technique, and consideration of postoperative radiation.

Ophthalmologic Clinical Features of Facial Nerve Palsy Patients

PURPOSE

To understand the ophthalmic clinical features and outcomes of facial nerve palsy patients who were referred to an ophthalmic clinic for various conditions like Bell's palsy, trauma, and brain tumor.

METHODS

A retrospective study was conducted of 34 eyes from 31 facial nerve palsy patients who visited a clinic between August 2007 and July 2017. The clinical signs, management, and prognosis were analyzed.

RESULTS

The average disease period was 51.1 ± 20.6 months, and the average follow-up duration was 24.0 ± 37.5 months. The causes of facial palsy were as follows: Bell's palsy, 13 cases; trauma, six cases; brain tumor, five cases; and cerebrovascular disease, four cases. The clinical signs were as follows: lagophthalmos, 24 eyes; corneal epithelial defect, 20 eyes; conjunctival injection, 19 eyes; ptosis, 15 eyes; and tearing, 12 eyes. Paralytic strabismus was found in seven eyes of patients with another cranial nerve palsy (including the third, fifth, or sixth cranial nerve). Conservative treatments (like ophthalmic ointment or eyelid taping) were conducted along with invasive procedures (like levator resection, tarsorrhaphy, or botulinum neurotoxin type A injection) in 17 eyes (50.0%). Over 60% of the patients with symptomatic improvement were treated using invasive treatment. At the time of last following, signs had improved in 70.8% of patients with lagophthalmos, 90% with corneal epithelium defect, 58.3% with tearing, and 72.7% with ptosis. The rate of improvement for all signs was high in patients suffering from facial nerve palsy without combined cranial nerve palsy.

CONCLUSIONS

The ophthalmic clinical features of facial nerve palsy were mainly corneal lesion and eyelid malposition, and their clinical course improved after invasive procedures. When palsy of the third, fifth, or sixty cranial nerve was involved, the prognosis and ophthalmic signs were worse than in cases of simple facial palsy. Understanding these differences will help the ophthalmologist take care of patients with facial nerve palsy.

Quantitative Analysis of Paralyzed Lower Eyelid Elevation Technique: Suspension Sling versus Supporting Midcheek Lift

BACKGROUND

Restoration of paralytic lower eyelid retraction is challenging in the surgical management of facial paralysis. In this study, quantitative measurements were compared between the suspension sling and lower eyelid-supporting midcheek lift techniques.

METHODS

From 2014 to 2016, 36 operations were performed on 28 patients with a mean age of 45.6 years (range, 7 to 80 years), a mean denervation time of 13.5 years (range, 0.2 to 44 years), and a mean follow-up period of 636 days (range, 261 to 1143 days). The surgical techniques included autologous tendon sling (n = 9), Mitek suspension (n = 12), and midcheek lift (n = 15). The distance from the pupil center to the lower eyelid margin was measured, and the ratio of the distance on the paralyzed side to that on the normal side was analyzed.

RESULTS

The change in the ratio between the paralyzed side and the normal side was 0.098 (from 1.264 to 1.166; p = 0.353) in the autologous tendon sling group, 0.104 (from 1.231 to 1.127; p = 0.243) in the Mitek suspension group (p = 0.05), and 0.179 (from 1.234 to 1.055; p = 0.038) in the midcheek lift group. Two patients in the Mitek suspension group developed foreign body infection.

CONCLUSIONS

The midcheek lift group showed the greatest change in the ratio between the distance from the pupil center to the eyelid margin on the paralyzed side and that on the normal side. Eyelid-supporting midcheek lift is superior to suspension sling for restoration of paralytic eyelid retraction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Medial canthoplasty for the management of exposure keratopathy

PURPOSE

To report the surgical technique and functional outcomes of the medial canthoplasty for the treatment of exposure keratopathy.

PATIENTS/METHODS

An IRB approved, retrospective review of patients who underwent medial canthoplasty for exposure keratopathy was performed. Patient demographics, reported symptoms, and clinical examination findings were collected and analyzed from pre-operative and follow-up visits.

RESULTS

The study included 73 consecutive cases in which the medial canthoplasty was performed in patients with exposure keratopathy. The average follow-up period was 7.9 months (median: 4.7 months; range: 1-150 months). Complete or partial improvement in ocular symptoms (dryness; pain/irritation; tearing) was achieved in 95% (69/73). Clinically, 85% (41/48) of patients demonstrated a post-operative reduction in lagophthalmos and 90% (60/67) showed improvement in ocular surface findings. Complications were rare (1/73) and reversal of medial canthoplasty was not required in any case.

CONCLUSIONS

The medial canthoplasty appears to be a safe and effective technique to narrow the palpebral fissure, provide lower eyelid support, and improve keratopathy. It is an uncomplicated procedure that may be considered for the treatment of exposure keratopathy caused by facial paralysis and lower eyelid malposition.

Red Eye: A Guide for Non-specialists

BACKGROUND

Red eye can arise as a manifestation of many different systemic and ophthalmological diseases. The physician whom the patient first consults for this problem is often not an ophthalmologist. A correct assessment of the urgency of the situation is vitally important for the planning of further diagnostic evaluation and treatment.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed in August 2016 as well as on the authors' own clinical and scientific experience.

RESULTS

Primary care physicians typically see 4-10 patients per week who complain of ocular symptoms. Most of them have red eye as the major clinical finding. A detailed history, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (uni- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for by a general practitioner from diseases calling for elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.

CONCLUSION

The differential diagnosis of red eye can be narrowed down rapidly with simple baseline tests and targeted questioning. Patients with ocular emergencies should be referred to an ophthalmologist at once, as should all patients whose diagnosis is in doubt.