Lagophthalmos: An etiological lookout to frame the decision for management

Purpose:

To describe the etiology, clinical profile, duration of lagophthalmos cases and thereby, framing a decision for the management based on the severity of Exposure keratitis (EK), Facial palsy (FP) with each etiology and to describe the outcome of the management options.

Methods:

The method was a prospective review of 120 lagophthalmos cases treated at a single tertiary center from January 2018 to January 2019. The main outcome measures were analysing the association between age, etiology, duration and management of lagophthalmos.

Results:

Of the 120 patients studied, paralytic etiology was noted in 86 and eyelid etiology in 34 patients. The percentage of various lagophthalmos etiology documented were Bell’s palsy (35.83%), lagophthalmos in ICU patients (15%), traumatic facial palsy(FP) (10.80%), stroke associated FP (6.67%), infection associated FP (6.67%), iatrogenic FP, cicatricial lagophthalmos (5%), lagophthalmos post eyelid surgeries (5%), neoplastic FP(3.33%), congenital FP (1.67%), proptosis induced lagophthalmos (1.67%), floppy eyelid syndrome induced lagophthalmos (0.83%) and lid coloboma associated lagophthalmos (0.83%). A statistically significant correlation was noted between exposure keratitis and age, with an increased prevalence age advances. The management showed significant variation with individual etiology, with some etiologies unquestionably requiring surgical management. Surgical management is crucial as the duration of lagophthalmos increases more than 6 weeks, EK involving pupillary axis and poor FP recovery.

Conclusion:

This study concludes that the conservative management was sufficient in all cases when the duration is less than 1 week, Exposure keratitis not involving the pupillary axis (EK< Grade II) and FP with good functional recovery ( FP < Grade III). The predominant causes being Bell’s palsy, lagophthalmos in ICU patients and vascular FP. Whereas, cases with poor functional recovery of facial palsy(FP) and permanent eyelid deformation require definitive surgical management like Traumatic FP & cicatricial lagophthalmos.

A non-surgical approach to the management of exposure keratitis due to facial palsy by using mini-scleral lenses

RATIONALE

This is a retrospective study aimed to determine the efficacy of mini-scleral contact lens in protecting the cornea and improving vision in cases of facial palsy.

PATIENT CONCERNS

Patients with facial palsy get exposure keratitis because the cornea is dry. They feel pain, discomfort and excessive watering. If left untreated, it leads to permanent damage to the cornea and loss of good functional vision. Mini-scleral lens keep the cornea covered by saline solution all wearing hours.

DIAGNOSES

Three patients (4 eyes) with acoustic neuroma, two unilateral and one bilateral, who underwent acoustic neuroma surgeries resulting in facial palsy, are presented.The gold implant and lateral tarsorrhaphy were not enough for corneal protection.Two patients (patients 1 and 2) suffered continuous pain and watering. They had to apply thick lubricant, Lacri-Lube ointment (Allergan, Inc., Dublin, Ireland), several times daily to the affected eye for 15 years. The vision of these patients in the affected eyes were counting fingers (CF) at one foot.Patient 3 with bilateral facial palsy had exposure keratitis in both eyes resulting in constant watering, pain and blurred vision.

INTERVENTIONS

The 4 eyes were fitted with mini-scleral lenses. The lenses were 15.8 mm rigid gas permeable filled with preservative free saline solution that continuously covers the cornea all wearing hours.

OUTCOMES

In patients 1 and 2 with unilateral facial palsy, vision improved through the mini-scleral lenses to 20/30 and all their symptoms disappeared.The keratitis in case 3 with bilateral facial palsy disappeared within one week of mini-scleral lens use.Follow up for 2 years showed that these patients maintained good vision with no side effects.

LESSONS

Mini-scleral lenses protected the cornea, gave comfort and improved the vision and the quality of life of these three patients with facial palsy and should be considered for all patients with facial palsy.

Augmentation of lateral tarsorrhaphy in lagophthalmos

Lagophthalmos, the inability to close the eyelids completely, is a serious condition caused by orbicularis oculi muscle paresis or paralysis. The standard lateral tarsorrhaphy may leave the eye open with corneal exposure. In those cases, we suggest that better approximation of the upper and lower eyelids will be achieved when the lower lid is retracted laterally and the upper lid medially. This yields satisfactory closure of the eyelids. I report herein four patients who were successfully treated with permanent lateral tarsorrhaphy with this approximation of the upper and lower eyelids with effective, satisfactory outcomes.