BACKGROUND:
Unilateral facial paralysis is associated with
lagophthalmos, exposure keratitis, corneal ulceration, lower lid ectropion,
laxity, ptosis, and epiphora. Functional and cosmetic restoration of the upper
and lower eyelids is essential in avoiding ocular complications in paralysis.
The choice of the optimum management can be difficult given the differences of
extent of nerve dysfunction, duration, etiology, age, and expectations.
METHODS:
Protection of the globe requires that dysfunction of both
the upper and lower eyelids be addressed simultaneously. Based on literature
review and surgical experience, algorithms are created for the upper eyelid and
the lower eyelid with success of treatment assessed by outcome. As defined by
etiology, pathways will be different for congenital, acquired temporary and/or
partial, and acquired permanent unilateral paralysis.
Conservative measures of corneal protection are always essential
from the onset of paralysis. Success of management of the upper eyelid is evaluated
by corneal coverage, improvement of dryness,
and resolution of keratitis. Gold weight implant insertion, insertion of a metallic
spring, and dynamic muscle (Temporalis) reconstruction are compared. Lower
eyelid management may include vertical lid suspension, horizontal shortening, composite
tissue grafts, dynamic muscle reconstruction, and tarsorraphy. Outcome markers
are correction of ectropion, ptosis and scleral show, and improvement of
epiphora. Insufficient support post reconstruction, subsidence, and recurrence of
ptosis are reviewed.
Patients with unilateral congenital paralysis are younger
when they seek management for increasing ocular problems. The upper eyelid is mostly
responsible for the lagophthalmos with the lower lid showing better tone and
support. Early scleral show with retained apposition is present. Treatment is
usually directed to the upper eyelid.
The etiology and duration of paralysis is an important
factor in treatment management. A partial paralysis e.g. Bell's Palsy, may vary
in severity and time to recovery. Continued exposure will indicate upper lid
management either permanent or temporary. Recovery of the lower eyelid from
partial paralysis may result in eventual increased height and tension, and
possible synkinesis.
Complete unilateral
acquired paralysis in adults will result in early corneal exposure and require
upper and lower eyelid management soon after onset.
RESULTS:
Gold weight implants were successful in improvement of
corneal exposure in 91% of patients. An extrusion rate of 10% over time was
appreciated. Vertical support of the lower eyelid is subject to approximately
21% subsidence rate, related to orbital and zygoma anatomy. A combination of
procedures can be developed from the algorithm to ensure optimum eyelid closure
and corneal protection. Static procedures are compared to outcome results of dynamic
reconstructions of the eyelids. Secondary procedures and the addition of
composite tissue should be considered in long standing ectropion where tissue
deficiencies of vertical shortening are apparent. The aesthetic results of anatomic
surgical reconstructions are compared to functional but disrupting tarsorraphies
for complete appreciation.
CONCLUSIONS:
Static gold weight implant to the upper eyelid provides an immediate improvement
of many corneal symptoms. Vertical support of the lower eyelid improves ptosis,
ectropion, and epiphora. Combinations of management are often necessary. Early
specific upper and lower eyelid intervention will preserve corneal health.