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Transcript of Facial Nerve Paralysis: Management of the Eye · PDF fileFacial Nerve Paralysis: Management of...
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Facial Nerve Paralysis:
Management of the Eye
Sam J. Cunningham, MD, PhD
Faculty Advisor: David C. Teller, MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
March 29, 2006
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Facial Nerve Paralysis:
Management of the Eye
Introduction
Anatomy
Options
Discussion of Literature
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Introduction-Facial Nerve Paralysis Functional and cosmetic problems
Upper lid fails to drop down and close
Lower lid loses tone and sags downward
– May evert leading to ectropion
Produces lagophthalmos and consequent corneal exposure.
Interruption of the tear film
Leads to drying of cornea,
– Ocular discomfort
– Corneal ulcers
– Infection
– Perforation
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Introduction-Facial Nerve Paralysis
Increased risk of complications:
– Poor Bell phenomenon
– Corneal anesthesia
– Pre-existing dry eye
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Normal Eye Closure
Contraction of the obicularis oculi
results in lowering the upper lid
Elevation of the lower lid
contributes minimally
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Anatomy
Eyelid functions
– Protect eye (light, injury, desiccation)
– Tear production and distribution
Extremely thin skin (upper > lower)
Skin
– Little subcutaneous fat
– Adherent over the tarsus (levator aponeurosis)
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Anatomy
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Anatomy
Horizontal length – 30 mm
Palpebral fissure – 10 mm
Margin reflex distance
– Number of millimeters from
the corneal light reflex to the
lid margin
– Upper lid – 4 to 5 mm (rests
slightly below limbus)
– Lower lid – 5 mm (rests at the
lower limbus
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Anatomy
Tarsus
– Dense, fibrous tissue
– Contour and skeleton
– Contain meibomian
glands
– Length – 25 mm
– Thickness – 1 mm
– Height
Upper plate – 10
mm
Lower plate – 4
mm
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Anatomy – Muscles
Protractor-Facial nerve
– Orbicularis
Retractors-Oculomotor
– Levator
– Müller’s
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Anatomy: Upper and lower lids
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Orbicularis Oculi Muscle
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Anatomy: Obicularis
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Levator palpebral superioris
and Müller’s muscle
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Lower Lid Anatomy
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Anatomy
Orbital Septum
– Fascial barrier
– Underlies posterior
orbicularis fascia
– Defines anterior extent
of orbit and posterior
extent of eyelid
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Anatomy
Canthal tendons
– Extensions of preseptal & pretarsal orbicularis
– Lateral slightly above medial
– Lateral tendon attaches to Whitnall’s tubercle
1.5 cm posterior to orbital rim
– Medial tendon complex, important for lacrimal
pump function
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Medial Canthal Tendon
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Lateral Canthal Tendon
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Canthal Tendons
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Lacrimal System
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Lacrimal Excretory Pump
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Facial Nerve Paralysis:
Management of the Eye
Initial treatment
– Ophthalmic drops/ointments (Jelks 1979)
– Protective taping, occlusive moisture chambers,
soft contact lenses, scleral shields (Goren and
Clemis 1973)
– Tarsorrhaphy suture
Majority of patients require definitive surgical
treatment to correct chronic impairment
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Facial Nerve Paralysis:
Management of the Eye
Surgical options include:
– Temporalis muscle transfer (Gillies)
– Encircling the upper and lower eyelids with
silicone or fascia lata (Freeman)
– Palpebral springs (Levine,May)
– Tarsorrhaphy (McLaughlin)
–Lid loading (Sheehan, others)
– Combinations
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Surgical Procedures
Palpebral Spring
– Advantages
Less visible
– Disadvantages
Technically difficult
Higher risk of extrusion
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Tarsorrhaphy
Poor cosmesis
Decreased peripheral
vision
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Surgical Procedures
Lower lid shortening
– Wedge excision with
lateral canthopexy
– Used in combination with
gold weight implantation
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Lid Loading
Early technique
– Incision in the supratarsal crease
– Subcutaneous pocket
– Insert weight
– Close skin
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Lid Loading-Early Technique
Stainless steel – High profile
– Migratory
– High rate of extrusion
Gold – Higher density - more weight in same size
– Malleable - conforms to the globe-lower profile
– Lower reactivity
– Reversible
– Migratory
– High rate of extrusion
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Gold Weight
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Surgical Procedures Gold weight implant-
placed beneath levator aponeurosis
– Advantages
Technically straightforward
Consistent
– Disadvantages-less than with previous technique
Less Visibility
Less Extrusion
Less Mobility
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Gold Weight
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Gold Weight Placement
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Combination of Gold Weight and
Lower Lid Shortening
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Combination of Gold Weight and
Lower Lid Shortening
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Platinum Chain
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Relevant Literature
Kinney et al: “Oculoplastic Surgical
Techniques for Protection of the Eye in
Facial Nerve Paralysis”
– Described an algorhythm for surgical
management of corneal exposure 2nd to CNVII
paralysis
– Auricular cartilage vs lateral canthotomy vs
dissection of suborbicularis oculi fat pad
(SOOF) vs brow elevation……….
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Ocular Management Paradigm
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Literature
Snyder et al: “Early vs Late Gold Weight
Implantation for Rehabilitation of the
Paralyzed Eyelid”
– Evaluated outcomes and complications of early
(<30 days) vs late (>30 days) gold weight
implantation
– 89.2% achieved satisfactory lid closure
– Statistically similar lid closure and complication
rates
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Literature
Foda: “Surgical Management of
Lagophthalmos in Patients with Facial
Palsy”
– Gold weight in combination with canthoplasty
– Complete correction of lagophthalmos and
ectropion with resolution of pre op symptoms in
92.5% of patients.
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Literature
Jobe: 2080 procedures with gold weight implants.
– Only 3% patients with reported complications
Harrisberg et al: 103 patients with gold weight
implants
– 46 had weights removed
78% due to facial nerve recovery
22% due to cosmetic dissatisfaction, implant
becoming too superficial, migration, partial
extrusion (implanted into prefashioned soft
tissue pocket in the preseptal space)
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Literature
Chepeha et al: 16 patients
– Lagophthalmos: pre op 7.5mm, post op 0.5mm
– Corneal coverage: pre op 73%, post op 100%
– High patient satisfaction
– No extrusions
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Conclusions
Gold weight implants safe and effective
Early implantation-reversible
Excellent results when used in combination
with lower lid shortening
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Bibliography
Foda, H Surgical Management of Lagophthalmos in Patients with Facial Nerve Palsy. American Journal of Otolaryngolgoy Vol 20, No6, 1999.
Jobe, R A Technique for lid loading in the management of lagophthalmos of facial palsy. Plast Reconstruct Surg. 53; 1974
Tremolada, C Temporal galeal fascia cover of custom-made gold lid weights for correction of paralytic lagophthalmos: long term evaluation of an improved technique.
Chang, L A useful augmented lateral tarsal strip tarsorrhaphy for paralytic ectropion. Ophthalmology. Vol113, No 1. 2006.
Harrisberg, B Long term outcome of gold eyelid weights in patients with facial nerve palsy. Otology and Neurotoloty. 22, 2001.
Chepeha, D Prospective evaluation of eyelid function with gold weight implants and lower eyelid shortening for facial paralysis. Acrh of Oto Head and Neck Surg. 127(3) 2001.
Kinney S Oculoplastic surgical techniques for protection of the eye in facial nerve paralysis. Am Jour Otology. 21: 2001.
Snyder M Early vs late gold weight implantation for rehabilitation of the paralyzed eyelid. Laryngoscope. 111: 2001
Lavy J Gold weight implants in the management of lagophthalmos in facial palsy. Clinical Otolaryngology. 29:2004
Caesar R Upper lid loading with gold weights in paralytic lagophthalmos: a modified technique to maximize the long-term functional and cosmetic success. Orbit 23 (1). 2004.
Berghaus, A The platinum chain: a new upper-lid implant for facial palsy. Arch Facial Plast Surg vol 5.2003.
Kao C Retrograde weight implantation for correction of lagophthalmos. Laryngoscope. 114:2004.