Facial Plast Surg 2008; 24(2): 220-230
DOI: 10.1055/s-2008-1075838
© Thieme Medical Publishers

The Evaluation and Treatment of Upper Eyelid Paralysis

Chris M. Bergeron1 , Kris S. Moe1
  • 1Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington
Further Information

Publication History

Publication Date:
09 May 2008 (online)

ABSTRACT

Patients with upper lid paralysis suffer from a loss of the blink reflex/response in the affected eye, leaving the eye vulnerable to a host of predatory insults. Partial or total impairment of the orbicularis oculi muscle, lagophthalmos, disruption of the lacrimal apparatus, upper lid retraction, and the unopposed pull of gravity on the surrounding paralyzed tissues all contribute to increased corneal exposure and an increased risk of exposure keratitis. Management of the upper lid in these patients must therefore focus on restoration of the effects of the blink reflex/response and prevention of corneal exposure. Relevant anatomy and pathophysiology are discussed. The initial treatment is supportive, with surgery reserved for those patients that fall into two categories: those who have failed nonsurgical treatment to protect the cornea and those who have been treated effectively with conservative measures but are faced with the prospect of long-term or permanent paralysis. A variety of surgical procedures that may be classified as either static or dynamic are discussed. Standard static procedures include lid loading and tarsorrhaphy, whereas the palpebral spring implant and the temporalis muscle transfer are classified as dynamic. The goal of the corrective procedures is to allow complete eye closure, thereby providing corneal protection, with minimal (1 mm or less) ptosis in the open position.

REFERENCES

  • 1 De Diego-Sastre J I, Fernandez-Garcia F. The epidemiology of Bell's palsy.  Rev Neurol. 2002;  41 287-290
  • 2 Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies.  Acta Otolaryngol Suppl. 2002;  (549) 4-30
  • 3 Seiff S R, Seiff B D. Anatomy of the Asian eyelid.  Facial Plast Surg Clin North Am. 2007;  15 309-314
  • 4 Dutton J. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia, PA; WB Saunders 1994
  • 5 Nesi F, Lisman RD, Levine MR Smith's Ophthalmic Plastic and Reconstructive Surgery. St. Louis, MO; Mosby 1998
  • 6 Aiache A E, Ramirez O H. The suborbicularis oculi fat pads: an anatomic and clinical study.  Plast Reconstr Surg. 1995;  95 37-42
  • 7 Doane M G. Interactions of eyelids and tears in corneal wetting and the dynamics of the normal human eyeblink.  Am J Ophthalmol. 1980;  89 507-516
  • 8 Stava M W, Huffman M D, Baker R S, Epstein A D, Porter J D. Conjugacy of spontaneous blinks in man: eyelid kinematics exhibit bilateral symmetry.  Invest Ophthalmol Vis Sci. 1994;  35 3966-3971
  • 9 Schmidtke K, Büttner-Ennever J A. Nervous control of eyelid function. A review of clinical, experimental and pathological data.  Brain. 1992;  115(Pt 1) 227-247
  • 10 Evinger C, Manning K A, Sibony P A. Eyelid movements. Mechanisms and normal data.  Invest Ophthalmol Vis Sci. 1991;  32 387-400
  • 11 Huffman M D, Baker R S, Stava M W, Chuke J C, Rouholiman B R, Porter J D. Kinematic analysis of eyelid movements in patients recovering from unilateral facial nerve palsy.  Neurology. 1996;  46 1079-1085
  • 12 Moe K S. Advances in the management of facial paralysis. In: Eisele D Complications in Head and Neck Surgery. Philadelphia, PA; WB Saunders (in press)
  • 13 Beuerman R W, Schimmelpfennig B. Sensory denervation of the rabbit cornea affects epithelial properties.  Exp Neurol. 1980;  69 196-201
  • 14 Kinney S E, Seeley B M, Seeley M Z, Foster J A. Oculoplastic surgical techniques for protection of the eye in facial nerve paralysis.  Am J Otol. 2000;  21 275-283
  • 15 Seiff S R. Surgical management of seventh nerve paralysis and floppy eyelid syndrome.  Curr Opin Ophthalmol. 1999;  10 242-246
  • 16 Koroloff N, Boots R, Lipman J, Thomas P, Rickard C, Coyer F. A randomised controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient.  Intensive Care Med. 2004;  30 1122-1126
  • 17 Ellis M F, Daniell M. An evaluation of the safety and efficacy of botulinum toxin type A (BOTOX) when used to produce a protective ptosis.  Clin Experiment Ophthalmol. 2001;  29 394-399
  • 18 Gusek-Schneider G C, Erbguth F. [Protective ptosis by botulinum A toxin injection in corneal affectations].  Klinische Monatsblätter Für Augenheilkunde . 1998;  213 15-22
  • 19 Smellie G D. Restoration of the blinking reflex in facial palsy by a simple lid-load operation.  Br J Plast Surg. 1966;  19 279-283
  • 20 Chuke J C, Baker R S, Porter J D. Bell's palsy-associated blepharospasm relieved by aiding eyelid closure.  Ann Neurol. 1996;  39 263-268
  • 21 Schrom T, Loch A, Hölzl M, Scherer H. [Evaluation of a new lid implant for rehabilitation of the paralyzed eye].  Laryngorhinootologie. 2006;  85 38-42
  • 22 Jobe R P. A technique for lid loading in the management of the lagophthalmos of facial palsy.  Plast Reconstr Surg. 1974;  53 29-32
  • 23 Berghaus A, Neumann K, Schrom T. The platinum chain: a new upper-lid implant for facial palsy.  Arch Facial Plast Surg. 2003;  5 166-170
  • 24 Choo P H, Carter S R, Seiff S R. Upper eyelid gold weight implantation in the Asian patient with facial paralysis.  Plast Reconstr Surg. 2000;  105 855-859
  • 25 Seiff S R, Sullivan J H, Freeman L N, Ahn J. Pretarsal fixation of gold weights in facial nerve palsy.  Ophthal Plast Reconstr Surg. 1989;  5 104-109
  • 26 Gilbard S M, Daspit C P. Reanimation of the paretic eyelid using gold weight implantation. A new approach and prospective evaluation.  Ophthal Plast Reconstr Surg. 1991;  7 93-103
  • 27 Schrom T, Wernecke K, Thelen A, Knipping S. [Results after lidloading with rigid gold weights-a meta-analysis].  Laryngorhinootologie. 2007;  86 117-123
  • 28 Schrom T. [Lidloading in facial palsy].  Laryngorhinootologie. 2007;  86 634-638
  • 29 Kao C-H, Moe K S. Retrograde weight implantation for correction of lagophthalmos.  Laryngoscope. 2004;  114 1570-1575
  • 30 Seiff S R, Chang J. Management of ophthalmic complications of facial nerve palsy.  Otolaryngol Clin North Am. 1992;  25 669-690
  • 31 Moe K S, Linder T. The lateral transorbital canthopexy for correction and prevention of ectropion: report of a procedure, grading system, and outcome study.  Arch Facial Plast Surg. 2000;  2 9-15
  • 32 Moe K S, Kao C-H. Precaruncular medial canthopexy.  Arch Facial Plast Surg. 2005;  7 244-250
  • 33 Morel-Fatio D, Lalardrie J P. Palliative surgical treatment of facial paralysis. The palpebral spring.  Plast Reconstr Surg. 1964;  33 446-456
  • 34 Levine R E, Shapiro J P. Reanimation of the paralyzed eyelid with the enhanced palpebral spring or the gold weight: modern replacements for tarsorrhaphy.  Facial Plast Surg. 2000;  16 325-336
  • 35 McNeill J I, Oh Y H. An improved palpebral spring for the management of paralytic lagophthalmos.  Ophthalmology. 1991;  98 715-719
  • 36 Levine R E, Pulec J L. Eyelid reanimation with the palpebral spring after facial nerve graft surgery: an interdisciplinary approach.  Ear Nose Throat J. 1993;  72 686-691
  • 37 Morgan L R, Rich A M. Four years' experience with the Morel-Fatio palpebral spring.  Plast Reconstr Surg. 1974;  53 404-409
  • 38 Levine R E. The three R's of initial eye care in facial paralysis: re-wet, restore, and re-close. In: Update on Facial Nerve Disorders. Alexandria, VA; American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. 2001: 267-275
  • 39 Gilles H D. Experiences with fascia lata grafts in the operative treatment of facial paralysis.  Proc R Soc Med. 1934;  2 1372-1384
  • 40 Byrne P J, Kim M, Boahene K, Millar J, Moe K. Temporalis tendon transfer as part of a comprehensive approach to facial reanimation.  Arch Facial Plast Surg. 2007;  9 234-241
  • 41 Hassan A S, Frueh B R, Elner V M. Mullerectomy for upper eyelid retraction and lagophthalmos due to facial nerve palsy.  Arch Ophthalmol. 2005;  123 1221-1225
  • 42 Catalano P J, Bergstein M J, Sen C, Post K. Management of the eye after iatrogenic facial paralysis.  Neurosurgery online. 1994;  35 259-262 discussion 262

Chris M BergeronM.D. 

Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Harborview Medical Center

325 Ninth Avenue, Box 359894, Seattle, WA 98104-2420