63.1 Introduction

Perhaps the most immediate and debilitating complication resulting from facial paralysis is the loss of complete eye closure. Impaired lid function may result in pain and irritation of the eye, and in severe untreated cases, corneal disease, exposure keratitis, and potentially vision loss.s. Literatur Synkinesis and gustatory lacrimation add to the potential long-term morbidity of aberrant facial nerve regeneration.

Management of the eye is challenging. Prognosis varies widely depending on etiology, patient demographic, and other medical comorbidities. No reliable method of prognosticating recovery existss. Literatur and many protective interventions interfere with the potential for spontaneous recovery.

63.2 Presentation and Etiology

Lid dysfunction in the setting of facial nerve paralysis results from loss of orbicularis oculi function, which normally opposes the levator palpebrae superioris muscle. The balance of these two opposing muscles allows the eye to remain open for light collection, while maintaining the protective and restorative function of the blink reflex and eye closure.

Blinking is primarily an upper lid function, with only 1 to 2 mm of the palpebral aperture traversed by the lower lid. Resting tone keeps the lid against the globe and in good position to oppose the superior lid, and to assist in the natural lateral-to-medial tear flow. Closure of the superior lid sweeps debris from the cornea into the inferior lid trough, and lacrimal fluids along with protective balanced salts and antibodies are collected along the sill of the lower lid to be spread across the cornea in a thin film. Lacrimation is stimulated by parasympathetic impulses through the greater superficial petrosal branch of the facial nerve.

Levine and Shapiro summarize three primary responsibilities of the functioning lids. Literatur:

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  Function 1: Define the limits of the palpebral aperture, limiting surface area of the globe exposed to evaporation.

  
  
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  Function 2: Close the palpebral aperture voluntarily to protect the cornea against potential injury and keep the cornea covered during sleep.

  
  
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  Function 3: Distribute tear film across the eye, and clear debris.

Facial nerve paralysis impairs all three functions of the eyelid, and restoration of these should be the focus of any intervention (Fig. 63‑1 ).

63.3 Decision Making

Many reanimation interventions may wait for a patient’s final degree of recovery, but protection of the cornea cannot. Immediate intervention is warranted to prevent permanent corneal damage, particularly in the setting of concomitant trigeminal neuropathy which may occur with large vestibular schwannoma.

63.4 Nonsurgical Treatment Options

Noninvasive eye care should be initiated as soon as paralysis is detected. Maintaining ocular lubrication with methylcellulose drops multiple times daily is a mainstay of treatment. Nighttime use of petroleum or mineral oil-based ointment will provide a longer-lasting lubricant, but may obscure vision during daytime function.

Many of the initial issues may be addressed temporarily by using medical tape on the lid while sleeping. Tape can be applied to the lower lid/lateral canthus to improve ectropion, or along the superior lid lash line to assist with mild lagophthalmos during the day. A moisture chamber fashioned from petroleum jelly to the orbital rim and cellophane is useful in patients who fail lid taping due to tape sensitivity or technique.

Scleral contact lenses have been described as a good long-term solution for corneal protection in paralytic lagophthalmos.s. Literatur Consideration warrants an ophthalmologic evaluation, and involves a large transparent scleral shield applied to the eye with a reservoir of saline that ensures corneal protection and prevents desiccation. Shields are usually well tolerated by patients, and provide better visual acuity over ocular lubricants, though application takes practice.s. Literatur

63.5 Surgical Treatment Options

Failure of nonsurgical treatment options, or an expectation of long-term paralysis, warrants consideration for surgical intervention. Improvement in patient-reported quality-of-life FaCE survey scores has been well demonstrated after proper surgical management of the eye by Henstrom et al.s. Literatur

Levines. Literatur listed criteria for surgery as follows:

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  Symptomatic patients with signs of conjunctival or corneal injury despite maximal medical therapy.

  
  
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  Patients who require rapid ocular rehabilitation to resume their livelihood.

  
  
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  Patients with a stable ocular status, but at high risk for corneal complications (concomitant cranial nerves V and VII palsy, poor Bell’s phenomenon).

Exposure of the patient to surgical risk, or interference with spontaneous nerve recovery, warrants careful consideration before any operative intervention.

63.5.2 Lid Loading

Loading of the upper lid involves placement of a dense material, such as gold or platinum weights, that uses gravity to oppose the levator muscle and improve eye closure. They work best during waking hours when a patient is upright, maximizing the effect of gravity on the implant. At night, patients may still need to manually pull the upper lid closed, sleep with their head elevated, or continue with eye taping to prevent corneal exposure when lying supine.

Weight/size is determined preoperatively by securing nonsterile sizers to the patient’s upper lid skin with adhesive. A weight is chosen that allows for maximal lid closure that still allows the patient minimal pseudoptosis at rest.

Gold weights have long been the standard of treatment of paralytic lagophthalmos. Gold has several advantages as an alloplast, including a high specific gravity, minimal tissue reactivity in its pure form (99.99% for 24k), and a color similar to fat. It is a nonferrous metal and is MRI compatible. Gold is malleable, and can be either purchased or custom made for an individual. Implantation technique is straightforward and usually does not require additional manipulation. They can be removed or exchanged in the setting of spontaneous recovery or patient preference.s. Literatur

Rates of adequate eye closure with gold are cited between 22 and 91%,s. Literatur ^,​ s. Literatur with closure sufficient to cover the cornea in 78% of cases,s. Literatur and improvement in visual acuity and complete resolution of exposure keratitis in 62 to 100% of cases.s. Literatur The most commonly reported complication is extrusion of the implant, resulting from infection, tight skin closure, injury, or allergic reaction to Neosporin.s. Literatur Weights are also reported to occasionally shift position, the incidence of which is decreased significantly by suturing the weight to the tarsal plate.s. Literatur

Platinum has emerged as a viable alternative to gold. The authors advocate the use of platinum for the increased density (platinum 21.5 g/cm³ vs. gold 19.4 g/cm³) allowing for a similar weight with less foreign material. Platinum has also been observed histologically to cause less tissue inflammation than gold.s. Literatur The platinum chain is also available, which has been reported to conform more closely to the patient’s globe.s. Literatur An additional alternative to solid implantable weights include external taping of weightss. Literatur or the injection of hyaluronic acid to the upper eyelids. Literatur (Fig. 63‑2 ).

Related posts:

62 Nonoperative Facial Rehabilitation in Vestibular Schwannoma: Facial Neuromuscular Retraining 69 Vestibular Rehabilitation and “PreHab” in Sporadic Vestibular Schwannoma 70 Management of Pre- and Posttreatment Trigeminal Neuralgia in Vestibular Schwannoma 65 Hypoglossal-to-Facial Nerve Transfer with Parotid Release for Rehabilitation of the Paralyzed Face in Vestibular Schwannoma 67 Gracilis Free Flap Rehabilitation of the Paralyzed Face in Vestibular Schwannoma 64 Interposition Cable Nerve Graft of the Facial Nerve After Resection of Vestibular Schwannoma

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