Long-Term Outcome of Gold Eyelid Weights in Patients With Facial Nerve Palsy

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].

[Nonspecific inflammatory reaction after implantation of palpebral implants]

PURPOSE

To identify the possible cause of an inflammatory reaction to a Russian-manufactured palpebral implant made of gold in the long term after surgery, and to determine the clinical and morphological changes in the tissues of the upper eyelid when the presence of the implant caused the inflammatory reaction.

MATERIAL AND METHODS

The results of 150 operations with placement of a palpebral implant were analyzed. In 12 cases, a nonspecific inflammatory reaction was revealed within 2 to 4 weeks after the operation, in 7 cases it necessitated explantation, in 5 cases the local long-term use of an ointment with a corticosteroid made it possible to avoid extrusion and explantation. Chemical microanalysis of the palpebral implant and fragments of the removed capsule was performed using scanning electron microscopy (SEM), as well as immunohistochemical (IHC), macro- and microscopic examination of the fragments of connective tissue capsule was carried out after removal of the palpebral implant.

RESULTS

The obtained data confirm the chemical purity of the implant, the absence of abnormal accumulation of metals in the tissues of the eyelid. IHC, macro- and microscopic examination of the presented fragments of the connective tissue capsule revealed signs characteristic of an inflammatory reaction to a foreign body.

CONCLUSION

Further research is needed to establish the factors and predictors for the development of inflammatory reactions to a foreign body and, in particular, to gold.

Sutureless Transconjunctival Insertion of Eyelid Weights: A Novel Technique

PURPOSE

To describe a novel surgical technique for implanting eyelid weights via a sutureless transconjunctival approach. In comparison to the traditional supratarsal crease approach, this technique does not involve any external incisions or suture placement. The procedure can reduce surgical time and complications associated with the traditional external approach.

METHODS

This case series includes 13 patients who underwent eyelid weight placement via the transconjunctival approach for paralytic lagophthalmos secondary to facial nerve paralysis (12 patients had unilateral paralysis and 1 patient had bilateral) with a total of 14 eyelid weights placed. The procedures were performed at an outpatient office-based surgical center. All procedures were performed or supervised by the same surgeon. Patients were followed for an average 6-month postoperative period for postoperative complications.

RESULTS

The sutureless transconjunctival approach to eyelid weight insertion was successful in achieving the desired functional and aesthetic outcomes. Patients undergoing this technique avoided the discomfort of postoperative suture removal. All patients achieved comparable outcomes postoperatively. There were no complications reported across the 13 patients throughout the 6-month postoperative period.

CONCLUSIONS

This case series demonstrates that the transconjunctival approach for metal eyelid weight insertion is practical, relatively easy to perform, and associated with functional outcomes that are comparable to those achieved with the traditional approach, however, without external incision or placement of sutures.

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.

[Biointegration properties of eyelid weight implants made of various materials (experimental study)]

Palpebral eyelid weight implants are currently considered as the gold standard method for lagophthalmos correction. Manufactured from different precious metals, they have both benefits and drawbacks. The article presents the results of an experimental morphological study of biointegration of different eyelid weight implants used for correction of paralytic lagophthalmos.

PURPOSE

To investigate biointegration properties of implants made of gold, platinum and platinum-gold alloy.

MATERIAL AND METHODS

The study enrolled 4 Chinchilla rabbits (8 eyelids). Palpebral implants manufactured of gold, platinum and platinum-gold alloy were placed into the eyelids of the experimental animals. The morphological examination was performed 1 and 6 months after the implantation using paraffin sections.

RESULTS

Light microscopy revealed that the implant beds were surrounded by pronounced fibrovascular capsule of uneven thickness over the whole follow-up. The capsule formed after the placement of an implant made of gold and platinum alloy was more loose. However, the emerging connective tissue bridges of the capsule contributed to its immobilization in the tissues and lower risk of extrusion. No signs of an inflammatory and/or allergic reaction were observed in any of the cases.

CONCLUSION

The obtained results show that implants made of a 90/10% platinum-gold alloy and 999.9 fine platinum have similar biointegration in terms of morphological features during 6 months of the follow-up period.

Blink detection and magnetic force generation for correction of lagophthalmos, with specific regard to implant compatibility testing

PURPOSE

The overall goal was to restore a normal and synchronous blink in unilateral lagophthalmos. We describe the biocompatibility profiling of a novel ferromagnetic implant used for electromagnetic eyelid force generation.

METHODS

A non-contact blink detection system and an electromagnetic stimulation system were designed and tested. A modified Lester-Burch speculum equipped with strain gauge technology was used in blinking force measurement. Samarium-cobalt magnets were prototyped and coated with parylene-C. Biocompatibility testing was performed using NIH/3T3 mouse fibroblast cells with MTT colorimetric assay cytotoxic quantification.

OUTCOME MEASURES

Cellular viability and interleukin concentrations.

RESULTS

Our system was capable of detecting 95.5 ± 3.6% of blinks in various lighting conditions. Using our force measuring device, the difference between non-paralyzed and paralyzed orbicularis oculi (OO) for normal and forceful blinking closure was 40.4 g and 101.9 g, respectively. A 16.6 × 5.0 × 1.5 mm curved shaped samarium cobalt eyelid implant was successfully developed and showed a reproducible blink at 100 ms with full corneal coverage with external eyelid taping. Compared to gold weights, parylene-C coated samarium cobalt implants showed not only excellent cell viability (82.0 ± 4.9% vs. 88.4 ± 0.9%, respectively, p > .05), but also below detection threshold for pro-inflammatory marker concentrations (interleukin-6 < 2 pg/mL and interleukin-10 < 3 pg/mL).

CONCLUSIONS

We demonstrated excellent in-vitro biocompatibility of our parylene-C coated samarium cobalt implants. We believe that our novel approach can improve the quality-of-life of affected individuals and provides new understanding of blinking biomechanics.

Orbicularis Oculi Muscle Reinnervation Confers Corneal Protective Advantages over Static Interventions Alone in the Subacute Facial Palsy Patient

BACKGROUND

Corneal protection is a priority in flaccid facial palsy patients. Denervation of the orbicularis oculi muscle results in weak palpebral closure and predisposes patients to severe corneal sequelae. While periorbital static procedures enhance corneal coverage in repose, voluntary closure is only regained through dynamic reinnervation of the muscle. This study aims to elucidate the added effect of dynamic reinnervation of the orbicularis oculi muscle on long-term corneal integrity as well as on dynamic closure of the palpebral aperture.

METHODS

Retrospective review was performed on two groups of complete palsy patients: those who received solely periorbital static procedures and those who underwent concomitant orbicularis oculi muscle reinnervation and static lid procedures. Only patients with complete ophthalmic examinations were included. Corneal punctate epithelial erosions in addition to static and dynamic palpebral measurements were serially assessed preoperatively and postoperatively.

RESULTS

Of 272 facial palsy patients, 26 fit the inclusion criteria. Eleven patients underwent combined muscle reinnervation involving facial-to-masseteric nerve coaptation in addition to static eye procedures, and 15 patients underwent solely static interventions. Analysis revealed a 65.3 percent lower mean punctate epithelial erosion score in reinnervation patients as compared with static patients when evaluated at more than 9 months postoperatively (p < 0.01). Reinnervation patients were also found to have 25.3 percent greater palpebral aperture closure (p < 0.05) and 32.8 percent higher closure velocity (p < 0.01) compared with static patients.

CONCLUSION

In patients with subacute facial palsy, dynamic reanimation of the orbicularis oculi muscle with concomitant static interventions provides lasting corneal protection not seen in patients who receive solely static interventions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Late outcomes of gold weights and platinum chains for upper eyelid loading

AIM

To identify late outcomes of gold weights (GWs) and platinum chains (PCs) for upper eyelid loading in the management of lagophthalmos.

METHODS

A retrospective case series of upper eyelid GWs and PCs at a single centre over a 10-year period (2004-2013). Two independent, blinded assessors graded standard photographs for any weight-related morbidity (poor upper eyelid contour, weight prominence and migration).

RESULTS

Primary upper eyelid loading (high-tarsal technique) was performed in 154 eyelids of 136 patients (facial nerve palsy, n=99; non-paralytic, n=37). A total of 127 eyelids of 110 patients had primary GW insertion. Of these, 40.9% (52/127) had revision surgery: exchange of GW for PC (58%), GW repositioning (25%) and removal of GW (17%). Only 22.2% (6/27 eyelids) with primary PCs required revision surgery. In those not requiring revision surgery, photograph grading showed that both GWs and PCs had weight-related morbidity at late follow-up (median=37.5 months, range 12-110 vs median=33.5 month, range 15-106). GWs had significantly higher rate of weight prominence (p=0.001) and migration (p<0.001) compared with PCs. All PC revisions required one procedure only compared with 10% of GWs revisions requiring two or more procedures. Incidence of gold allergy was 7% (8/110 patients). There was no association between the choice of weight material, physical weight or suture material and eyelid morbidities.

CONCLUSION

GWs were found to be associated with higher complications and twice more likely to require long-term revision surgery compared with PCs. Despite weight fixation at a high-tarsal location, prominence of PCs can still occur.

Post-septal upper eyelid loading for treatment of exposure keratopathy secondary to non-cicatricial lagophthalmos

Exposure keratopathy may result in ocular surface dryness, pain, corneal ulceration and loss of vision. Upper eyelid loading is an effective surgical treatment for paralytic lagophthalmos but has been criticised for complications of implant exposure and poor cosmesis. We therefore reviewed the safety and efficacy of our technique of upper eyelid post-septal loading for exposure keratopathy in this context. A retrospective case notes analysis was undertaken of 38 patients who had upper eyelid loading, all with post-septal weight placement, for correction of lagophthalmos. Patient demographics, indications for surgery, outcomes and complications were analysed. The mean age of all patients was 59.6 years. Exposure keratopathy was secondary to facial nerve paralysis in all but two patients, with tumor excision being the commonest underlying aetiology (63.8%). The mean implant weight used was 1.4 grams. Pre-operatively, all 38 patients had ocular discomfort despite maximal use of lubricating eye drops but post-operatively, 29 patients (76.3%) were comfortable without any such drops. Mean lagophthalmos on blink and gentle closure improved from 7.42mm and 5.47mm pre-operatively to 2.18mm and 1.18mm post-operatively (p < 0.001). Similarly, before surgery all patients had some corneal staining but after surgery 37 patients (97.4%) had none. The gold weight was removed in four patients (10.5%), due to chronic inflammation in three and due to mild astigmatism in one. No patient had exposure of the weight and one patient had a ptosis repair 6 months after surgery. Upper eyelid loading was effective in reducing both signs and symptoms of exposure keratopathy related to lagophthalmos in our series. Patients were very satisfied with the surgical outcome and complications related to exposure and cosmesis were very rare.

Levator lengthening technique using cartilage or fascia graft for paralytic lagophthalmos in facial paralysis

INTRODUCTION

Lid loading using gold weights has been commonly used to treat paralytic lagophthalmos (PL); however, the procedure has a relatively high complication rate and the availability of these plates varies among social circumstances. We used a levator lengthening (LL) technique, which originally elongated the levator aponeurosis by inserting a fascia graft between the edge of the levator aponeurosis and the tarsal plate. However, because this procedure tends to result in a wide residual lagophthalmos, we changed the graft material from fascia to conchal cartilage. In this study, we describe in detail our experience with LL using the cartilage graft.

METHODS

LL was performed in 18 patients with PL. Fascia grafts were used in seven patients and cartilage grafts in 11. Static reconstructions of the lower eyelid and eyebrow were also performed in most patients. Efficacy was evaluated from patient reports of ocular symptoms and by measuring the palpebral fissure width at opening and closing for both eyes.

RESULTS

All patients experienced improved ophthalmological symptoms, which were more apparent in cartilage cases. The average palpebral fissure at eyelid closure was 1.8 mm in cartilage cases and 4.0 mm in fascia cases. In cases where an eyebrow lift was concurrently performed, the residual lagophthalmos became wider in fascia grafting but remained acceptable in cartilage grafting.

DISCUSSION

LL is a simple and useful procedure for treating PL with higher efficacy when a cartilage graft is used. However, the level of the upper eyelid can be easily adjusted by changing the fixation position of the cartilage. Additional experience is required to obtain more consistent outcomes.

Effectiveness of the lower eyelid suspension using fascia lata graft for the treatment of lagophthalmos due to facial paralysis

PURPOSE

To evaluate of functional and cosmetic effectiveness of lower eyelid sling technique with fascia lata graft in patients with lagophthalmos due to facial paralysis.

MATERIAL AND METHOD

Ten patients with a mean age of 55.1 ± 19.77 years who underwent lower eyelid sling surgery with a fascia lata graft between September 2011 and January 2014 were included in this prospective study. Preoperatively and postoperatively patients were evaluated in terms of corneal epithelial defects, Schirmer's test, and tear break-up time (TBUT). Cosmetically, vertical eyelid aperture, margin reflex distances 1 and 2 (MRD1 and MRD2) and scleral show were evaluated preoperatively and postoperatively.

RESULTS

One patient had facial paralysis on the right side whereas the other 9 patients had facial paralysis on the left side. Preoperatively, 3 patients were detected with corneal ulcer, whereas 7 patients were detected with persistent corneal epithelial defects localized in the lower half of the cornea. In the 3 patients with preoperative corneal ulcer, the ulcer recovered with corneal opacity, whereas in the 7 patients with punctate epitheliopathy, postoperative corneal transparency was obtained.

DISCUSSION

Lower eyelid sling technique with fascia lata graft is an effective technique for the repositioning of the lower eyelid and preventing the corneal complications.

[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.

Treatment of migration and extrusion of the gold weight eyelid implant with fascia lata sandwich graft technique

Gold weight implantation is generally considered a safe procedure for the treatment of paralytic lagophthalmos. The most frequently seen complications are extrusion, malpositioning, and migration of the implant. To decrease the rate of these complications, several modifications were defined in the composition and the shape of the implant as well as the surgical technique itself. Despite these precautions, implant revision rates are still as high as 8% to 14%. Nowadays, implant-covering or implant-wrapping procedures are becoming more popular to avoid implant-related problems. However, there is limited information in the literature regarding the management of these complications. In this study, we aimed to present the treatment of migration and extrusion of the gold weight implant in a patient with Moebius syndrome by wrapping the implant with autogenous fascia lata graft.

Treatment of the Periocular Complex in Paralytic Lagophthalmos

Objectives:

Paralytic lagophthalmos can lead to devastating exposure keratitis. The main surgical intervention consists of upper eyelid loading. However, adjunctive lower eyelid and brow procedures are also available as necessary. We sought to analyze the use of periocular procedures in paralytic lagophthalmos at Johns Hopkins.

Methods:

The method was a retrospective review of patients treated at a single tertiary care center from 2006 to 2012.

Results:

One hundred one patients met inclusion criteria, and 20 patients were excluded for not meeting the minimum follow-up. Upper eyelid loading was required on 95/101 patients (95%). Adjunctive procedures were necessary in 73% (73/101) of patients. Lower eyelid procedures were used in 47% (47/101) and brow lifts in 47% (47/101). Older patients (>50 years) were more likely to require lower eyelid procedures ( P = .04) and more likely to require revision ( P = .003). Medial canthopexy and direct brow lift were associated with the need for revision ( P = .006, P = .03).

Conclusion:

Paralytic lagophthalmos management is not one-size-fits-all. Upper eyelid loading is the mainstay of treatment; however, adjunctive procedures to the lower eyelid and brow are indicated in the majority of patients. Our retrospective review has allowed us to continue to refine our strategy for managing these patients.

Noninfectious inflammatory reaction to a gold weight eyelid implant: A case report and literature review

Upper eyelid loading with a gold weight is a generally well-tolerated procedure that helps reduce corneal exposure in patients with lagophthalmos. Complications of this procedure are infrequent. The authors present a rare case of a noninfectious inflammatory response to an eyelid gold weight implant in a 48-year-old woman and summarize all previously published cases. This particular patient presented with incomplete left eyelid closure secondary to a trauma. After having a gold weight inserted into her eyelid to improve closure, she returned with edema and erythema of the eyelid. The inflammation did not respond to oral antibiotics; however, oral steroid therapy resulted in prompt resolution of her symptoms. Her symptoms recurred after discontinuing steroid use and she subsequently required removal of her gold weight implant for permanent resolution of her eyelid inflammation. Although rare, this reaction poses a serious management issue, because it does not respond to antibiotics or short-term steroid use and, in most cases, requires removal of the gold implant.

Facial nerve damage following surgery for cerebellopontine angle tumours. Prevention and comprehensive treatment

Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20-70% of patients. Facial nerve paresis is observed in 10-40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.

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.

Palpebral spring in the management of lagophthalmos and exposure keratopathy secondary to facial nerve palsy

PURPOSE

To evaluate the use of a palpebral spring, a dynamic facial reanimation technique, in the management of lagophthalmos and exposure keratopathy secondary to facial nerve palsy.

METHODS

A palpebral spring was placed in 29 eyelids of 28 patients with symptomatic facial nerve palsy. Preoperative and postoperative symptoms, upper eyelid margin to midpupil distance, lagophthalmos, and exposure keratopathy were evaluated.

RESULTS

At an average of 83 months follow-up, preoperative symptoms improved or resolved in 26 (90%) eyes. The upper eyelid margin to midpupil distance decreased and lagophthalmos and exposure keratopathy significantly improved after palpebral spring placement (p < 0.001). After modification of the technique by suturing the spring to the anterior tarsal surface, rather than encasing the tip in a silicone tube and letting it ride freely, tension of the spring required adjustment in 4 eyes (27%). Dislocation of the spring from the tarsus without exposure through the skin was observed in 1 eyelid (7%). The spring was replaced because of loss of function secondary to metal fatigue in 5 eyelids (33%) after an average of 43 months. Exposure of the spring through the skin was observed in 2 eyelids (14%) and required spring removal from 1 eyelid and replacement of the spring in the other.

CONCLUSION

A palpebral spring is an effective treatment for lagophthalmos and exposure keratopathy in patients with facial nerve palsy who do not receive adequate relief from the static procedures of lower eyelid tightening and upper eyelid lowering. This technique significantly improved symptoms and signs in these patients while allowing some of the blink reflex.

Ocular outcomes after gold weight placement and facial nerve resection

OBJECTIVE: To assess the effectiveness of acute gold weight placement after facial nerve resection and to determine the role of concomitant lower eyelid procedures.

STUDY DESIGN: Retrospective review.

SUBJECTS AND METHODS: Twenty-two patients who received an upper eyelid gold weight at the time of parotidectomy and facial nerve resection were reviewed to assess ocular outcomes.

RESULTS: After gold weight placement, twelve patients (12 of 22, 54.5%) subsequently presented with symptomatic ectropion (n = 9) and/or lagophthalmos (n = 5). Nine patients received a lower eyelid procedure (7 tarsal strips only, 1 tarsal strip combined with a lateral tarsorrhaphy, and 1 lateral tarsorrhaphy only). Six patients, in addition to a gold weight, also underwent a static sling to the midface at the time of facial nerve resection. None of these 6 received a subsequent lower eyelid procedure. Two patients required gold weight upsizing. Two patients required weight removal.

CONCLUSIONS: Insertion of 1.2 gm upper eyelid weight with placement of midface sling is recommended at the time of facial nerve resection. Due to the need to tighten the lower eyelid in many of these patients, we now also consider performing a tarsal strip procedure at the time of facial nerve resection in any patient with pre-existing lower lid laxity.

Patients' perspectives on the ocular symptoms of facial paralysis after gold weight implantation

SUMMARY

Upper lid loading for the treatment of lagophthalmos resulting from facial paralysis is a simple and effective procedure with relatively few side effects and complications. A detailed patient-based self assessment, focusing on subjective complaints after upper lid weight implantation is scarce. In this study, a population of facial palsy patients with lid weights is asked about their subjective complaints in order to find out the patients' point of view. Patients with upper lid weights were asked questions indicating the degree of soreness, tearing, redness, visual acuity, lid closing during the day, lid closing during sleep, aesthetic appearance, artificial tear utilisation and outdoor comfort. All questions were evaluated by an analogue scale in reference to the opposite eye, where a score of '10' corresponds to the best outcome (no symptoms at all or appearance comparable to the contralateral eye) and a score of '1' corresponds to the worst outcome. Thirty patients filled in the questionnaire and 22 of them were seen in the outpatient clinic. The most pleasing result was obtained in the lid closing during the day (score 8.8+/-1.9), during sleep (7.7+/-3.0) and in the aesthetic appearance of the eye (score 7.6+/-2.7), whereas visual acuity received the lowest score (score 5.7+/-1.5). Complication and re-operation rates were 23% and 13%, respectively. In conclusion, upper lid weights solve the problem they are used to address. They provide a satisfactory lid closure and aesthetic appearance in the patients' point of view. However, the ocular symptoms of facial paralysis still persist to some extent and the procedure is not without its complications.

Customized gold weight eyelid implantation in paralytic lagophthalmos

Gold eyelid implantation is widely considered the procedure of choice to reanimate the upper eyelid in paralytic lagophthalmos. Commercially supplied implants are not readily available in all places and are sometimes cumbersome to import.

OBJECTIVE

We aimed to devise a method whereby every surgeon performing gold eyelid implantation could have easy and quick access to the implant. Furthermore, we aimed to develop a means of creating an implant of the exact weight required for complete eyelid closure.

STUDY DESIGN AND SETTING

A prospective study was performed from 1997 to 2005 in a tertiary research hospital, involving 50 subjects requiring gold upper eyelid implantation and using the technique in question.

RESULTS

Only patients with a minimum follow up of one year were included in the study group. Symptoms improved in 96 per cent of subjects, who were able to dispense with eyedrops and eye ointments. Visual acuity improved in 92 per cent of patients. There were two extrusions amongst the early cases.

CONCLUSION AND SIGNIFICANCE

Customized gold eyelid implantation offers an alternative in regions where commercial implants are not easily obtained.

3D lithographically fabricated nanoliter containers for drug delivery

Lithographic patterning offers the possibility for precise structuring of drug delivery devices. The fabrication process can also facilitate the incorporation of advanced functionality for imaging, sensing, telemetry and actuation. However, a major limitation of present day lithographic fabrication is the inherent two-dimensionality of the patterning process. We review a new approach to construct three dimensional (3D) patterned containers by lithographically patterning two dimensional (2D) templates with liquefiable hinges that spontaneously fold upon heating into hollow polyhedral containers. The containers have finite encapsulation volumes, can be made small enough to pass through a hypodermic needle, and the 3D profile of the containers facilitates enhanced diffusion with the surrounding medium as compared to reservoir systems fabricated in planar substrates. We compare the features of the containers to those of present day drug delivery systems. These features include ease of manufacture, versatility in size and shape, monodisperse porosity, ability for spatial manipulation and remote triggering to release drugs on-demand, the incorporation of electronic modules, cell encapsulation, biocompatibility and stability. We also review possible applications in drug delivery and cell encapsulation therapy (CET). The results summarized in this review suggest a new strategy to enable construction of "smart", three dimensional drug delivery systems using lithography.

Static treatment of paralytic lagophthalmos with autogenous tissues

BACKGROUND

Long-standing facial paralysis is frequently seen in patients who have undergone surgical procedures with sacrifice of the facial nerve and have never been counseled about limiting its consequences. Lagophthalmos must always be treated in these patients to protect vision. The authors describe their techniques of static treatment for lagophthalmos using autologous tissues and their classification system for standardizing patients.

METHODS

From July 2001 to September 2005, 12 patients (9 men and 2 women) ranging in age from 37 to 77 years (mean, 58.5 years) were treated. Their paralysis was attributable to acoustic neuroma resection in seven cases, to resection of a cerebral vascular anomaly in two cases, and to total parotidectomy with facial nerve sacrifice in three cases. The patients were treated with elongation of the levator palpebrae superioris muscle using a fascia lata graft, bolstering of the lower eyelid with a conchal cartilage graft, or both, combined with a Kuhnt type resection when needed.

RESULTS

Complete closure was achieved for nine patients (75%). For all the patients, resolution of symptoms and keratitis was achieved. No complications were observed. The follow-up period ranged from 14 to 51 months (mean, 39.5 months). The cosmetic outcome also was satisfactory.

CONCLUSIONS

For candidates eligible to undergo static treatment of lagphthalmos, the techniques described may be considered valuable options for the correction of lagophthalmos using autologous tissues, thus avoiding the complications related to alloplastic material implantation.

Corneal Astigmatism With Upper Eyelid Gold Weight Implantation Using the Combined High Pretarsal and Levator Fixation Technique

PURPOSE

To evaluate corneal astigmatism with the combined high pretarsal and levator fixation gold weight implantation technique.

METHODS

Twenty-one eyelids of 21 patients with facial nerve palsy were prospectively enrolled. All patients underwent upper eyelid gold weight implantation using the combined high pretarsal and levator fixation technique. Keratometry and automated refraction were performed preoperatively and postoperatively. Five patients were excluded from final analysis because of incomplete keratometry data. The data were analyzed looking for statistically significant changes in lagophthalmos, automated refraction, and keratometry.

RESULTS

A statistically significant improvement in lagophthalmos with spontaneous blinking (p = 0.0014), and gentle (p = 0.0016) and forced (p = 0.0027) closure was noted postoperatively. No significant differences were found when comparing preoperative and postoperative automated refraction readings (p = 0.89, p = 0.88), automated refraction axis (p = 0.71), keratometry readings (p = 0.40, p = 0.77), or keratometry axis (p = 0.63).

CONCLUSIONS

Implantation of a gold weight in the upper eyelid with the combined high pretarsal and levator fixation technique does not appear to cause a significant change in corneal astigmatism. This is contrary to data for pretarsal gold weight implantation, which does induce significant with-the-rule corneal astigmatism.

Gold weight implantation for rehabilitation of the paralysed eyelid

Patients with complete facial nerve palsy are at risk of severe eye complications due to corneal exposure. Gold weight implantation improves function, cosmetic appearance and morbidity. Three patients with nerve palsy underwent insertion of precisely prepared gold weights between May 2000 and December 2001. Individual gold weights were implanted into a small pocket between the orbicularis oculi and the tarsal plate of the upper eyelid, fitting the curvature of the eye. According to follow-up examinations (after at least 5 years), none of the gold weights had extruded; all patients experienced marked improvement of their dry-eye symptoms and expressed a high degree of satisfaction. Implantation of gold weights is effective and should be considered in all patients for the management of paralytic lagophthalmos.

Postoperative functional evaluation of different reanimation techniques for facial nerve repair

BACKGROUND

The facial nerve function after facial-facial nerve anastomosis, grafting, hypoglossal-facial nerve anastomosis, hypoglossal-facial interpositional jump nerve anastomosis, or a combined approach was analyzed.

METHODS

Facial function was assessed after operation using a 7-point visual analog scale (VAS) and by electromyography (EMG) in 53 patients. The final result was judged by May's facial nerve grading system.

RESULTS

Voluntary EMG activity occurred on average 4.52 +/- 1.31 months after operation. Initial facial movements were visible after 5.41 +/- 1.80 months. Facial function related to the VAS finally reached 44% of normal value. The result was judged May's grade I in 13%, grade II in 34%, grade III in 28%, and grade IV in 25% of patients. A significant difference in outcome between different reconstruction types was not seen. Age over 60 years was related to worse outcome.

CONCLUSIONS

A correct selection of the best method in the individual situation presumed, all analyzed facial reanimation techniques seem to lead nearly similar and satisfactory results.

Nocturnal Lagophthalmos: An Overview and Classification

Nocturnal lagophthalmos is the inability to close the eyelids during sleep. Lagophthalmos is associated with exposure keratopathy, poor sleep, and persistent exposure-related symptoms. There are a variety of causes of lagophthalmos, grouped as proptosis/eye exposure etiologies and palpebral insufficiency etiologies. Although obvious lagophthalmos is usually detected, it is sometimes difficult to recognize obscure lagophthalmos, due either to eyelash obstruction or overhang of the upper lid anterior and inferior to the most superior portion of the lower lid in a closed position. We present a novel classification system and illustrations of obvious and obscure lagophthalmos. A diagnosis can usually be made with a focused history and slit lamp examination. Treatment is multipronged and may include minor procedures or ocular surgery to correct the lid malposition; natural, topical or oral agents; and punctal plugs to manage ocular surface effects. Correct and timely diagnosis allows greater opportunity for relief of patient suffering and prevention of severe ocular surface pathology, as well as educated planning for future ocular surgical procedures.

Type IV hypersensitivity reactions to upper lid gold weight implants-is patch testing necessary?

AIMS

To report two cases of allergic reaction to upper lid gold weight implants in patients with facial nerve palsy and to identify the use of pre-implantation patch testing in predicting gold hypersensitivity.

METHODS

One patient who had a positive family history of gold allergy and had undergone previous gold dental restoration underwent patch testing with gold sodium thiosulphate. The gold weight from the same patient was analysed using scanning electron microscopy and energy dispersive X-ray analysis, which can detect surface impurities. Tissue obtained during surgery to remove the gold weight from the second patient was examined histologically.

RESULTS

Patch testing in the first patient gave a positive result. Analysis of the gold weight removed from the same patient confirmed 99.99% purity, and hence sensitivity to the gold itself was considered to be the cause of the inflammatory reaction. Histology of tissue taken from the eyelid of the second patient was consistent with type IV hypersensitivity.

CONCLUSION

A personal and family history of gold allergy should be looked for before upper eyelid gold weight implantation. Patch testing should be performed for patients where there is doubt about whether gold has been the specific cause of previous allergic reactions, for patients who have undergone previous dental restoration involving gold, or if there is a positive family history of gold allergy.

Facial Paralysis and Surgical Rehabilitation: A Quality Of Life Analysis in a Cohort of 1,595 Patients after Acoustic Neuroma Surgery

OBJECTIVES

On the basis of survey results of the Acoustic Neuroma Association, we report patient ratings of facial dysfunction and outcomes for various facial rehabilitative therapies after surgical treatment of acoustic neuroma (AN). We assessed patients' perceived quality of life (QOL) and reviewed the literature regarding facial dysfunction and its management associated with AN.

STUDY DESIGN

The Acoustic Neuroma Association mailed a detailed questionnaire to 2,372 members to identify preoperative and postoperative symptoms, complications, and long-term effects on physical and psychosocial function. A cohort of 1,595 (82.2%) respondents who underwent surgical treatment of ANs reported their experiences with facial dysfunction.

PATIENTS

Of all 1,940 survey respondents, 1,682 of 1,875 that had ANs underwent surgical treatment. The study included 1,595 patients with ANs (82.2% of all respondents) who underwent surgical treatment by way of the translabyrinthine, suboccipital, or middle fossa approaches and excluded 87 respondents who did not report the type of surgical approach.

METHODS

Respondents answered questions intended to qualify and quantify the degree that facial dysfunction impacted QOL parameters. Responses were analyzed for tumor size, surgical approach, patient age, and sex. Statistical analysis was performed using SPSS software.

RESULTS

In our analysis, 11% of all respondents experienced some degree of preoperative facial weakness or eye problems. Of all respondents, 45.5% (725 patients) experienced worsened facial weakness caused by surgery, and of these, 72% reported that it was permanent. The most commonly used successful therapy for facial reanimation for 271 (19.6%) patients was placement of a gold weight. The factor most often associated with poor outcome was a large tumor. Of all respondents, 28% felt significantly affected by facial weakness, 63% felt their smile was symmetric, and 70% were content "quite a bit" or "very much" with their QOL.

CONCLUSIONS

In this large cohort study of AN patients, facial dysfunction was a significant morbidity. Physicians should be aware of the risk factors identified, specifically large tumor size and the impact facial dysfunction has on QOL, when counseling patients regarding optimal management of AN.

Gold Weight Implantation: A Better Way?

PURPOSE

To introduce an alternative surgical technique for gold weight implantation for the treatment of lagophthalmos. We suggest that unwrapped intraorbital gold weight implantation provides adequate function, better cosmetic appearance, and lower morbidity than conventional implantation with wrapped or unwrapped pretarsal gold weights.

METHODS

The charts of a single surgeon were reviewed (1994 to 2003). All patients who underwent intraorbital gold weight implantation were included in the study. The technique was noted to be consistent with intraorbital fixation of a custom 2.2-gm gold weight (MedDev Corporation, Sunnyvale, California). Implants were not wrapped. Efficacy was defined as elimination of exposure keratopathy with preservation of the visual axis. Morbidity was defined as extrusion of the weight, shift of positioning requiring intervention, inflammation/infection of the eyelid, or poor cosmetic appearance.

RESULTS

Of 59 patient charts reviewed, 2 patients had morbidity as defined by our study: One had shifting of the gold weight, necessitating repositioning of the weight; the other had extrusion of the gold weight, requiring its removal. The remaining patients had no complaints or cosmetic concerns. Follow-up examinations found no incidence of exposure keratopathy.

CONCLUSIONS

We found intraorbital gold weight implantation, without the use of a wrap, to be simple and effective, with adequate function, an acceptably low postoperative morbidity rate, and an excellent cosmetic outcome.

The facial nerve in the presence of a head and neck neoplasm: assessment and outcome after surgical management

PURPOSE OF REVIEW

The face is the mirror of personality. Facial expression is the most important part of verbal and nonverbal communication. Patients with head and neck neoplasm and facial palsy are more stigmatized by the latter than by the tumor itself. Facial nerve reconstruction in such a patient is a great challenge. This review gives an overview of the assessment of facial palsy, surgical reconstruction, and postoperative treatment.

RECENT FINDINGS

MRI, CT, and electromyography are indispensable tools in the assessment of preoperative facial palsy in patients with head and neck neoplasm. When part of the facial nerve has to be sacrificed during surgery, the best functional results are achieved with direct facial nerve suture, interposition graft, or by a hypoglossal-facial nerve interposition jump anastomosis. The latter is the best choice when the reanimation is planned between 6 months and 2 years after tumor surgery. In any case, the eye is best rehabilitated with upper lid loading. Temporalis muscle transposition gives fast and good results for the restoration of the corner of the mouth after radical surgery. Reanimation by free muscle transfer for head and neck cancer patients is rarely indicated. Botulinum toxin treatment is an excellent postoperative aid for refining the result; the optimal modality of postoperative physiotherapy is still unclear.

SUMMARY

Surgical reanimation of the face in head and neck patients has reached a high standard. Strategies to decrease misdirected reinnervation after nerve suture have to be established in clinical practice for further improvement of facial rehabilitation.

Upper lid loading with gold weights in paralytic lagophthalmos: a modified technique to maximize the long-term functional and cosmetic success

PURPOSE

To describe a modified fixation technique to improve the long-term functional and cosmetic success of upper lid loading with gold weights.

METHOD

A retrospective single surgeon study of combined upper pre-tarsal and direct levator fixation of the gold weight. The minimum follow-up period was 12 months.

RESULTS

Gold weights were implanted with the modified technique into 29 patients. The gold weight was removed in two cases due to infection and in one case due to ptosis. There was no loss of function over the follow-up period and the cosmetic outcome was good or very good in all cases. The follow-up ranged from 12 to 84 months with a mean of 40 months.

CONCLUSIONS

Combined upper pre-tarsal fixation and direct levator fixation is effective in maximizing both the long-term functional and cosmetic success of upper lid loading with gold weights in paralytic lagophthalmos.

Processed Human Pericardium Barrier for Gold Weight Implantation

PURPOSE

To determine the safety and efficacy of processed human pericardium as a barrier material for gold weight implantation.

METHODS

In this retrospective, noncomparative case series, all patients undergoing gold weight implantation with human pericardium barrier between November 2000 and May 2002 were studied. Charts were reviewed for surgical indications, gold weight size, follow-up interval, and complications.

RESULTS

Twenty-three eyelids of 23 patients underwent gold weight implantation with processed human pericardium barrier material. There were 15 female and 8 male patients. Mean patient age was 53 years (range, 22 to 78 years). Indications for surgery included extruded implant (4 eyelids), thin tissues overlying existing implant (3 eyelids), thin anterior lamellar eyelid tissues (6 eyelids), radiotherapy (1 eyelid), and requirement for long-term gold weight therapy (9 eyelids). Mean follow-up was 11 months (range, 3 to 36 months). Acceptable tissue coverage was found in 23 of 23 eyelids. There were no complications of infection, extrusion, or thinning of overlying tissues. One patient had prolonged eyelid edema and erythema that resolved spontaneously 3 months after surgery.

CONCLUSIONS

Human pericardium appears to be well tolerated on at least a short-term basis within the eyelid when used as a barrier material for gold weight implantation.

A modified temporalis transfer in facial reanimation

A modified surgical procedure for temporalis transfer in facial reanimation of five consecutive cases is presented. Instead of the traditional stripping of the temporalis from its origin, its attachment at the coronoid removed, and to its end, the harvested fascia lata graft was sutured to lengthen the muscle's action. These fibres were then passed to the Orbicularis Oculi and Oris to aid in reanimation and to improve their tone. The procedure is less extensive, provides a direct line of pull with good functional results, no muscle atropy since vascularity and innervation is maintained. No complaints of paresthesia, hyposthesia or scar on donor leg was noticed. None of the patients required a revision of surgery for unacceptable contour or asymmetry. This simple procedure has helped reconstruction of natural symmetrical smile with highly successful results.