Gold weight implants in the management of lagophthalmos in facial palsy

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.

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.

Does lagophthalmos change on lying supine after upper eyelid platinum segment chain loading?

BACKGROUND

Facial nerve palsy (FNP) often significantly affects blink. Platinum segment chains (PSC) improve lagophthalmos, however, debate exists as to the effectiveness of weights when the patient lies supine.

METHODS

Prospective case series of patients with FNP following PSC insertion. Lagophthalmos on blink, gentle and forced closure was observed in the seated position, lying flat supine at 0 degrees, lying supine with one pillow underneath the head and lying on the side, with the non-facial palsy side to the pillow. This side was chosen to account for the effect that the pillow may have on lagophthalmos.

RESULTS

Twenty eyes with PSC for facial palsy related lagophthalmos were assessed in 19 patients. Clinically, 12 out of the 20 eyes had no change in lagophthalmos on gentle closure when sitting up compared to supine (no pillow). The remaining 8 eyes had an increase of lagophthalmos of mean 2.3 mm (range 1-6 mm) when supine. There was no statistical difference in the amount of lagophthalmos between sitting up and lying flat with no pillow on gentle closure (P value = .0804) and blink (P value = .1567). About 50% of patients have ongoing requirements for evening lubricating ointment application but only one patient in our cohort experienced morning ocular symptoms. No patient was taping their eyelids.

CONCLUSION

In our study, the prevalence of lagophthalmos increasing on gentle closure when supine is 40%. Statistically, there is no difference between gentle closure in the sitting and supine position.

Facial Nerve Trauma: Clinical Evaluation and Management Strategies

The field of facial paralysis requires the reconstructive surgeon to apply a wide spectrum of reconstructive and aesthetic principles, using a comprehensive array of surgical tools, including microsurgery, peripheral nerve surgery, and aesthetic facial surgery on the road to optimize patient outcomes. The distinct deficits created by different anatomical levels of facial nerve injury require a fundamental understanding of facial nerve anatomy. Palsy duration, followed by location and mechanism, will determine mimetic muscle salvageability, by means of either direct repair, grafting, or nerve transfers, whereas longer palsy durations will necessitate introducing a new neuromuscular unit, whether by muscle transfer or free functional muscle transplant. A thorough history, physical examination, and basic understanding of ancillary studies, emphasizing palsy duration, location, and mechanism of injury, are critical in evaluation, prognostication, and treatment strategies in traumatic facial palsy patients. The importance of ancillary and aesthetic procedures cannot be overstated. Although these do not provide motion, they constitute essential tools in the treatment of facial paralysis, providing both protective and improved aesthetic outcomes, yielding the highest impact in final surgeon and patient satisfaction, bringing our patients to smile not only on the outside, but also on the inside.

Evaluation of Corneal Morphology in Patients With Hemifacial Spasm

PURPOSE

To determine whether the corneal topographic parameter values, individual corneal layer thicknesses, and its endothelial layer morphology are different in patients with hemifacial spasm (HFS) than in the control contralateral eye.

METHODS

This study was designed as a prospective study. Among patients who applied to our hospital within the past 3-year period, those with HFS in one eye (study eyes) and a completely normal contralateral eye (control eyes) were included in this study. In addition to a complete ophthalmologic examination, all patients were scanned by the Pentacam Scheimpflug camera, and a corneal endothelium cell count was taken using a Topcon Specular Microscope. Also, the thickness of the corneal sublayers was measured on the central cornea with anterior segment module of spectral domain optical coherence tomography. Data entered using SPSS software were then evaluated by paired t test; P<0.05 value was considered statistically significant.

RESULTS

Twenty-eight patients (16 women and 12 men) were evaluated. Steep K, Kmax, and astigmatism values were significantly higher in the study eyes of patients with HFS than in the control eyes (P<0.05, for all). In addition, the total corneal thickness and corneal stromal thickness measurements in the study eyes were statistically significantly thinner than the control eyes (P=0.04 and P<0.001, respectively). Specular microscopy parameters were not statistically significant between the study eyes and control eyes (P>0.05, for all).

CONCLUSION

Corneal stromal thinning suggests that chronic exposure to hypoxia may induce this effect through extracellular matrix remodeling and losses in collagen framework content in patients with HFS.

Corneal and Tear Film Changes After Botulinum Toxin-A in Blepharospasm or Hemifacial Spasm

PURPOSE

To investigate changes in corneal parameters and the tear film after botulinum toxin-A (BTX-A) injection in patients with blepharospasm or hemifacial spasm.

METHODS

Twelve patients with benign essential blepharospasm and 30 with hemifacial spasm treated with BTX-A were included in this study. Disease severity was evaluated using the Jankovic scale. Corneal parameters were measured by the Pentacam. The Schirmer test score, tear breakup time, corneal fluorescein staining value, and Ocular Surface Disease Index score were also evaluated.

RESULTS

The BTX-A treatment relieved spasms in all of the patients. There was a statistically significant difference in disease severity between pretreatment and the third week (2.7 ± 0.8 and 1.3 ± 0.6, respectively; P < 0.001), but there was no statistically significant difference between pretreatment and the third month (2.7 ± 0.8 and 2.7 ± 0.8, respectively; P = 0.8). The tear breakup time was found to be significantly higher at both 3 weeks and 3 months after injection (6.6 ± 4.0 at pretreatment, 8.1 ± 3.9 at the third week, and 7.8 ± 4.2 at the third month; P = 0.04 and P = 0.02, respectively). The Schirmer test score, corneal fluorescein staining values, and Ocular Surface Disease Index score were lower 3 weeks after injection, but these values increased again by 3 months after injection. Corneal astigmatism decreased significantly at 3 weeks and at 3 months after injection [1.4 ± 1.2 diopters (D) at pretreatment, 1.2 ± 0.8 D at the third week, and 1.1 ± 0.8 D at the third month, respectively; P = 0.02, for both], but other corneal parameters did not change.

CONCLUSIONS

BTX-A injection therapy was affected the tear film in patients with blepharospasm or hemifacial spasm. However, there were no changes in corneal parameters, except corneal astigmatism, in these patients after treatment.

Microbial synthesis of gold nanoparticles: current status and future prospects

Gold nanoparticles have been employed in biomedicine since the last decade because of their unique optical, electrical and photothermal properties. Present review discusses the microbial synthesis, properties and biomedical applications of gold nanoparticles. Different microbial synthesis strategies used so far for obtaining better yield and stability have been described. It also includes different methods used for the characterization and analysis of gold nanoparticles, viz. UV-visible spectroscopy, Fourier transform infrared spectroscopy, X ray diffraction spectroscopy, scanning electron microscopy, ransmission electron microscopy, atomic force microscopy, electron dispersive X ray, X ray photoelectron spectroscopy and cyclic voltametry. The different mechanisms involved in microbial synthesis of gold nanoparticles have been discussed. The information related to applications of microbially synthesized gold nanoparticles and patents on microbial synthesis of gold nanoparticles has been summarized.

A new gyro-based method for quantifying eyelid motion

PURPOSE

We present an innovative method to quantify the eyeblink by using a miniature gyroscopic sensor (gyro), which is applied on the upper eyelid. Electrical Stimulation (ES) of the facial nerve is a promising technology to treat dysfunctional eyelid closure following facial paralysis. We used the new gyro-based method to evaluate the biomechanics of both the spontaneous and the ES-induced eyeblink, and to identify the best ES protocol.


METHODS

During blinking, eyelids rotate about the axis passing through the eye canthi, thus we propose to use a gyro for measuring the angular velocity of the upper eyelid (ωe  ). The angular displacement of the eyelid (θe  ) was calculated by integrating the ωe signal. Two indices were derived from θe: 1) the eyelid angular displacement during eye closure (C), calculated as the peak value of θe ; 2) the eyelid closure duration (D), calculated as the time interval between zero signal and the peak value of θe. In a healthy volunteer we used this method to quantify both the spontaneous eyeblink and the blinks elicited by different ES patterns.


RESULTS

For the spontaneous eyeblink, indices C = 14.0 ± 1.8° and D = 94.0 ± 10.8 ms were computed. By comparing C and D indices for spontaneous and ES cases, trains of 10 pulses with a frequency ranging from 200 Hz to 400 Hz proved to induce the most effective and natural-like eyeblinks.


CONCLUSIONS

The new gyro-based method proved to be a valuable tool to provide dynamic and real-time quantification of eyelid motions. It could be particularly useful for evaluating the effective and natural-like eyeblink restoration provided by ES.

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.

Intrinsic and therapeutic factors determining the recovery of motor function after peripheral nerve transection

Insufficient recovery after peripheral nerve injury has been attributed to (i) poor pathfinding of regrowing axons, (ii) excessive collateral axonal branching at the lesion site and (iii) polyneuronal innervation of the neuromuscular junctions (NMJ). The facial nerve transection model has been used initially to measure restoration of function after varying therapies and to examine the mechanisms underlying their effects. Since it is very difficult to control the navigation of several thousand axons, efforts concentrated on collateral branching and NMJ-polyinnervation. Treatment with antibodies against trophic factors to combat branching improved the precision of reinnervation, but had no positive effects on functional recovery. This suggested that polyneuronal reinnervation--rather than collateral branching--may be the critical limiting factor. The former could be reduced by pharmacological agents known to perturb microtubule assembly and was followed by recovery of function. Because muscle polyinnervation is activity-dependent and can be manipulated, attempts to design a clinically feasible therapy were performed by electrical stimulation or by soft tissue massage. Electrical stimulation applied to the transected facial nerve or to paralysed facial muscles did not improve vibrissal motor performance and failed to diminish polyinnervation. In contrast, gentle stroking of the paralysed muscles (vibrissal, orbicularis oculi, tongue musculature) resulted in full recovery of function. This manual stimulation was also effective after hypoglossal-facial nerve suture and after interpositional nerve grafting, but not after surgical reconstruction of the median nerve. All these findings raise hopes that clinically feasible and effective therapies could be soon designed and tested.

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.

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.

[Restoration of lid function in peripheral facial palsy by implanting gold weights]

BACKGROUND

Lagophthalmos is a common functional and aesthetic problem in patients with facial palsy. The implantation of a rigid gold weight is one technique to improve eyelid closure. The effectiveness of lid loading was investigated, taking into consideration complications ascribed to rigid implants.

PATIENTS AND METHODS

We present 11 patients with facial palsy treated with that technique between April 2001 and October 2005. Before and after operation ophthalmological investigations were performed. The patients were questioned about their subjective satisfaction, and the remaining eye lid gap in the closed state was assessed.

RESULTS

A good up to perfect lid closure could be achieved. Of the 11 patients, 9 reported being very contented with the result. Except for one case of extrusion, disturbed healing processes did not occur. We did not observe any occurrence of astigmatism as a result of the rigid lid load. All patients reduced their use of eye ointment and eye covers. We observed a visible bulging of the implant contour in 4 of 11 patients. However, not one of them felt discontented. All patients stated that they would undergo the lid loading procedure again.

CONCLUSIONS

The implantation of rigid gold weights for lid loading in patients suffering from lagophthalmos due to peripheral facial palsy is considered a simple and effective treatment for improving eyelid closure. Whether or not flexible implants will lead to better results needs to be further investigated.

Changes in Corneal Topography With Upper Eyelid Gold Weight Implants

PURPOSE

To determine the effect of upper eyelid gold weight implantation on corneal astigmatism.

METHODS

This is a prospective, cohort study. Eighteen eyes of 18 patients underwent upper eyelid gold weight implantation for facial nerve palsy. Nine of these patients recovered facial nerve function and underwent elective removal of the gold weight. Corneal topography was performed before and after gold weight implantation. Corneal topography was also performed after gold weight removal in patients who recovered from facial nerve paralysis.

RESULTS

With-the-rule corneal astigmatism increased significantly by 1.4 diopters (D) +/-2.0, from a mean of 0.3 to 1.7 D after gold weight implantation (p = 0.034). With-the-rule corneal astigmatism in patients who had gold weight removal decreased by 1.2 +/- 2.1 D, from 2.2 to 1.0 D after gold weight removal (p = 0.136).

CONCLUSIONS

Upper eyelid gold weight implantation causes an increase in corneal astigmatism, predominantly in the vertical axis, which appears to be reversible on removal of the gold weight.

The changes in corneal astigmatism after botulinum toxin-a injection in patients with blepharospasm

To determine if the involuntary contractions of eyelids may have any effects on the development of corneal astigmatism, we performed this prospective study which includes 19 patients with either essential blepharospasm or hemifacial spasm. In hemifacial spasm, the degree of corneal astigmatism was evaluated between two eyes. Then the topographic changes were checked using vector analysis technique before and after passively opening the eyelids. They were also measured before and at 1 and 6 months after the injection of Botulinum toxin. Resultantly, 20 eyes had the with-the-rule (group1) and 9 eyes against-the-rule (group2) astigmatism. In hemifacial spasm, significantly more astigmatism was found at spastic eyes. The corneal topographic changes after passively opening the eyelids showed 10 eyes with the astigmatic shift to the with-the-rule, while the remaining 19 to the against the- rule. At 1 month after injection of Botulinum toxin, group 1 showed reduced average corneal astigmatism, whereas group 2 showed increased astigmatism. The astigmatic change vector showed significantly more against-the-rule. In the contrary, 6 months after treatment, corneal astigmatism again increased in group 1 and decreased in group 2. So they took on the appearance of pretreatment astigmatic status eventually. Conclusively eyelids may play an important role in corneal curvature.