The aim of the study was to evaluate the outcome of upper
eyelid loading with gold weight implant in patients with lagophthalmos due to
facial palsy at King
Hussein Medical
Center. The indications,
results and complications were investigated.
Methods
A retrospective observational study that was conducted
at King Hussein Medical
Center during the period
between January 2005 and June 2008. Sixteen patients with facial palsy of different
etiologies were enrolled in the study. Inclusion criteria included lagophthalmos
of more than 5mm and facial palsy of at least 6 months duration.
The weight of the gold weight ranged from 0.7 to 1.6 grams (mean 1.2 g). The ideal weight was considered when complete voluntary closure was achieved without causing ptosis. The ideal weight selection was done by taping the demo lid weight to the upper lid, asking the patient to blink and then deciding the most suitable one. Weights come in steps from 0.6 to 1.6 grams. In ideal weight would improve eye closure without causing ptosis. A supratarsal lid crease incision was made and the weight was inserted at the junction of medial one third and lateral two thirds of the upper lid under the orbicularis and over the tarsus and fixed with 6-0 polypropylene sutures. All surgery was done under local anaesthesia (1% lidocaine hydrochloride with 1:100 000 epinephrine).
Degree of lagophthalmos and corneal coverage were assessed
pre and post operatively. After the immediate postoperative phase, patients
were followed up every 3 months, following the close follow up during early
postoperative period. Follow up period ranged between six months and three
years, the average being 18 months. Simple descriptive statistics was used to describe
the study variables
Results
The mean age of patients was 57.2 years with a male to
female ratio of 1.1:1. Table I shows the etiology of facial palsy for our
patients. The main cause of facial palsy was post cerebellopontine angle (C-P angle)
tumor surgery (10 patients). Other causes were Bell’s palsy (5 patients), trauma (one patient).
The degree of lagophthalmos improved from 5.8 mm to 0.8 mm on average. Corneal
coverage improved from 69% to 99%.
One patient (6.25%) developed insignificant migration
of the gold weight which did not affect the degree of corneal coverage. Two
patients (12.5%) developed mild postoperative astigmatism. One other patient (6.25%)
developed mild ptosis which could be due to an error in pre-operative measurement
of the accurate desirable weight, Table II.
Serious complications like postoperative infection or extrusion
did not occur in any patient.
Discussion
The ophthalmologist plays a
pivotal role in the evaluation and rehabilitation of patients with facial nerve
palsy.(1) The immediate ophthalmic priority is to ensure
adequate corneal protection. The medium to long-term management consists of
treatment of epiphora, hyperkinetic disorders secondary to aberrant
regeneration and poor cosmesis. Causes of facial palsy includes idiopathic or
Bell's palsy which is most common cause, infections such as herpes zoster of
the geniculate ganglion caused by (Ramsay Hunt syndrome), other viral
infections, tuberculosis, lyme disease, trauma, neoplasm and other causes such
as stroke.
This modality of treatment in
management of facial palsy was introduced to our center in January 2005 to give
more comprehensive care to patients with this problem. Some of the patients who
had significant corneal exposure despite having had a static lateral
tarsorraphy were best helped by having gold weight loading to their upper lids.
In our series we dealt with
cases of irreversible and complete facial palsy hence Bell's palsy was only
seen in 21.88% of cases in our study (as most cases of idiopathic
Bell's palsy have good prognosis). The most common cause we encountered was post
c-p angle tumor surgery accounting for more than two thirds of our patients.
Table I lists the causes of facial palsy in our series.
All our patients had their surgery
done under local anaesthesia by the same team. Degree of lagophthalmos and corneal
coverage were assessed pre and post operatively. Patients were assessed every 3
months after their surgeries after the early close postoperative period. Table III
shows the outcome of surgery after one year.
Lagophthalmos improved from 5.8
mm preoperatively to 0.8 mm post surgery. Corneal coverage was the patient's
best corneal coverage judged in percentages with 0%, 25%, 50%, 75%,
90%, and 100% cut-off points. Mean corneal coverage was 69% preoperatively and
improved to 99% one year after operation. Our review of the literature found
that results of upper lid gold weight loading are satisfactory in general with
good cosmetic and functional results.(2,4,5,11-12) A study conducted
by Chepeha and his colleagues showed lagophthalmos improvement from 7.5 mm to
0.5 mm, corneal coverage from 73% to 100%, and mean satisfaction
score from 3.5 to 7.1.(4) On the other hand, we found one
study with unsatisfactory results.(13) In that study
complication rate was 68%, distributed as follows infection in 7% of cases,
loss of position in 18%, and finally extrusion of the weight in 43%.
The use of gold implants is not
free from undesired effects. Reported complications include astigmatism, pseudoptosis,
migration, bulging, and extrusion. The most common undesired effect we encountered was
eye irritation that was reported in 22 patients. This was innocuous and
resolved by using artificial tears in all patients.
A low-grade astigmatism of the
cornea ranging from 1 to 2 D is seen in the approximately
vertical cut corresponding to the pressure of the gold implant from
above, as can be shown by means of corneal topographic photographs.(14)
Astigmatism only occurred in one of our patients and was corrected by
cylindrical lens. None of our patients had extrusion of the implant. Infection
did not occur in our patients.
It is worth mentioning that he
use of gold weight eyelid implants is certainly a desirable option for
treatment of patients suffering from lagophthalmos, but it is not always
successful or may not give the desired aesthetic result due to the thickness of
the prefabricated implants and the anatomical structures of the eye. There are
distinct anatomic differences between the Caucasian and Asian eyelids, which
dictate the overlying aesthetic differences. Commercially manufactured gold
implants are available in several weights and are usually used but may create a
“brick-like” appearance within the eyelid. Custom-made weights that produce a
much more aesthetic result can be fabricated by the dental professionals.15
Conclusion
The results of upper lid gold weight loading at King Hussein
Medical Center
showed that this operation is an effective and satisfactory procedure in
patients with lagophthalmos with minimal complications.
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