Lagophthalmos

Lagophthalmos is a condition in which patients are unable to close their eyelids.

Lagophthalmos leads to a diminished blink, incomplete eye closure, and impairment of the nasolacrimal system that produces and drains away tears. Symptoms include tearing and a weak eyelid. The main cause for paralytic lagophthalmos is Bell’s palsy, a form of facial paralysis due to facial nerve dysfunction. This dysfunction results in an inability to control facial muscles on the affected side.

Trauma, infections, tumors, or other conditions might also lead to lagophthalmos.

The blink reflex and eyelid position are critical to maintaining a healthy eye surface. Each blink spreads tear film over the eye and creates a continuous layer of moisture. Because of this, people with lagophthalmos should discuss treatment options with their physician.

Supportive Therapy

Lubrication with eye drops and eye ointments can effectively protect the cornea, but often result in substantially blurred vision. Eye protection such as eye patches, eye shields, moisture chambers, and night time taping will increase eye comfort, especially when eye drops and ointment alone are insufficient.

_External eyelid weights (tape-on weights) provide an immediate, voluntary blink mechanism for treating ocular exposure associated with lagopthalmos. This option is non-surgical and offers excellent comfort and ease of use.

Medical Therapy

Steroids (Cortisone) and antivirals are widely used to treat Bell’s palsy, but their effectiveness have not been clearly proven. Some studies show that steroid treatment within a short time after onset can improve the chance for complete recovery in 3 to 9 months. Other studies show that adding multivitamins and/or antiviral medicines might also improve outcome. [Do we have anything related to this that specifically ties to lagophthalmos?]

Surgical Therapy

Many surgical options re a possibility for lagopthalmos treatment. In most situations, the surgeon will use a combination of procedures tailored to the patient’s situation.

Most patients who have severe corneal exposure due to lagophthalmos (with or without a paralytic and sagging eyelid) are treated with a combination of eyelid tightening, eyelid lift, and gold-weight implantation. Patients without severe exposure receive a single procedure or combination of procedures.

Patients with a poor prognosis, identified by facial nerve testing or persistent paralysis, appear to benefit the most from surgical intervention.

 

Eyelid tightening SOOF lift, is designed to lift and suspend the midfacial musculature. Lifting the SOOF may also elevate the upper lip and the angle of the mouth to improve facial symmetry in patients with Bell’s palsy. A SOOF lift is commonly done in conjunction with a procedure to tighten the eyelid.  This procedure, known as a lateral tarsal strip procedure, corrects horizontal lower-lid laxity and improves the position of the lid to the globe.

Implantable devices (such as gold weight implants in the eyelid) can restore dynamic lid closure in cases of severe, symptomatic lagophthalmos. The physician inserts gold or platinum weights or palpebral springs into the eyelids. The implants are inert and composed of 99.99% pure gold or platinum, and are available in several sizes. They are easily removed if nerve function returns.

The weight allows the upper eyelid to close with gravity when the eyelid opening muscle is relaxed. Therefore, patients must sleep with their head slightly elevated.

Complications of weight implants can include migration of the implant, inflammation, allergic reaction, or extrusion.

Tarsorrhaphy decreases the patient’s horizontal lid opening by fusing the eyelid margins together to better support the precorneal lake of tears and improve coverage of the eye during sleep. The procedure can be performed laterally, centrally, or medially.

The lateral procedure is most common, but can restrict the patient’s peripheral vision. Central tarsorrhaphy offers good corneal protection, but occludes vision and can be cosmetically unacceptable. Medial tarsorrhaphy can offer good lid closure without substantially affecting the visual field.

Physicians can perform tarsorrhaphy in the office. The procedure is especially suitable for patients who are unable or unwilling to have another type of surgery. It can be completed as either a temporary or permanent measure.

Direct brow lift helps correct brown ptosis, or sagging eyebrows. Lifting the brow can cause lagophthalmos to worsen, however, especially if the patient has poor lid closure. The surgeon can prevent this complication by either placing a gold weight implant or performing lower lid resuspension when he completes the brow lift.

Transposition of the temporal muscle can reanimate the face and provide lid closure. The surgeon places strips from the muscle and fascia in the upper and lower lids as an encircling sling. Patients initiate movement by clenching their teeth or chewing.

Facial nerve grafting (hypoglossal-facial nerve anastomosis)re-innervates the facial nerve so movement is possible. Grafting may be performed on patients with clinically significant, permanent paralysis to help restore relatively normal function to the orbicularis oculi muscle or eyelids.

Note: The information for this section included a good bit of discussion on Bell’s palsy and facial nerve palsy. I included a brief definition of Bell’s palsy, but deleted the rest because it seemed to get too far off track from the focus on lagophthalmos. If the palsy/facial nerve info needs to be edited and added back to the document, I still have the original content.

 

Facial Nerve Palsy

Facial nerve paralysis is a common problem that involves the paralysis of any structures innervated by the facial nerve. The pathway of the facial nerve is long and relatively convoluted, and so there are a number of causes that may result in facial nerve paralysis. The most common is Bell’s Palsy, a disease that may only be diagnosed by exclusion. A facial nerve palsy may be caused by physical trauma, especially fractures of the temporal bone. Other causes include herpes zoster infection and tumors that compress the facial nerve anywhere along its complex pathway. Common tumor culprits are facial neuromas, congenital cholesteatomas, acoustic neuromas, parotid gland neoplasms, or metastases (spread) of other tumors.

Bell’s Palsy

Bell’s palsy is a form of facial paralysis resulting from a dysfunction of the seventh cranial nerve (the facial nerve), which results in the inability to control facial muscles on the affected side. Several conditions can cause facial paralysis such as a brain tumor, stroke, and Lyme disease. However, if no specific cause can be identified, the condition is knows as Bell’s palsy.

Bell’s palsy is usually self-limiting. The hallmark of this condition is a rapid onset of partial or complete palsy that often occurs overnight. In rare cases (<1%) it can occur bilaterally resulting in total facial paralysis. It is thought that an inflammatory condition leads to swelling of the facial nerve. The nerve travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily identifiable cause for Bell’s palsy has been found.

In either situation, a thorough medical history and physical examination are the first steps in making a diagnosis and beginning the proper treatment.

Inability to Close Eyelids

Patients with lagopthalmos (inability to close their eyelids) have several treatment options available to them:

Treatment

Lubrication. Ointments are very effective in protecting the cornea, but they often result in substantially blurred vision.

Eyelid weights. External lid weights provide an immediate, voluntary blink mechanism for treating ocular exposure associated with temporary facial paralysis such as Bell’s palsy. This option is non-surgical and offers excellent comfort and ease of use.

Surgery

Horizontal Closure (lateral tarsorraphy)

This has been the standard method of managing inflammation of the cornea (exposure keratitis) and is often effective if large enough. However, large tarsorrhaphies may be disfiguring and limit peripheral vision. Medial tarsorrhaphies are more disfiguring and are generally used as a last resort.

Vertical Closure

  • lower-lid elevation
  • fascia lata or silicone sling to the lower eyelid
  • hard palate or Alloderm implant
  • midface lift

Upper Eyelid Lowering

  • Inserting a gold weight (0.6 to 1.6 grams) in the upper eyelid
  • The surgeon makes an incision at the upper lid crease and secures the weight in position. 
  • The weight allows the eyelid to close more easily.
  • Excess weight, however, may cause ptosis (eyelid droop).