Examination for facial palsy
Before considering treatment, a full history and ophthalmic examination must be performed by the oculoplastic surgeon. The visual acuity is first measured and the cornea examined for dryness, exposure and ulcers. To make sure that there are no serious underlying causes of the condition, you may need a full neurological assessment by a neurologist including neuroimaging techniques such as a CT scan or MRI.
The oculoplastic surgeon will then conduct a thorough examination of the patient’s entire face, including the forehead, eyebrow, eyelid closure, orbicularis muscle strength, Bell’s phenomena, lid laxity, cheek and mouth. The eyelid examination is the most important part for planning the treatment. As assesment of eyelid laxity, palpebral aperture, corneal sensation and, possiblty, tearduct tests may also be performed.
The surgeon may take photographs / videos to document the face and eyelids movements.
Symptoms of facial palsy
A patient with facial palsy gets dry eye from lack of blinking, tear evaporation and inability to close the eye fully. The natural response is to produce excess tears which cannot drain due to the eyelid muscle (orbicularis oculi) weakness and pump failure. The patient experiences a paradoxically watering eye, when it is also dry and exposed. Facial palsy patients with eye involvement have a potentially site threatening condition that must be assessed and treated by an oculoplastic surgeon from the beginning. The surgeon will monitor the vision and decide what treatment is required.
Preserving patient’s vision and ocular comfort in facial palsy
The treatment of facial palsy is first directed at preserving the patient’s vision, secondly their ocular comfort, and thirdly correcting facial asymmetry and improving function. Good vision requires a normal tear film with normal position and function of the eyelids. The following medical and surgical treatments are used in the rehabillitation in patients with facial nerve palsy. Many of these surgeries also address the correction of the asymmetry, e.g. brow lifting, upper lid lowering and lower eyelid tightening and elevating as well as mid-face lift.
1. Medical Treatment
- Dry eyes are treated medically using a plethera of lubricating eye drops and gels.
- Lagophthalmos can be treated with simple measures such as padding or taping the eyes shut at night can help prevent corneal damage.
- Severe dry eyes are treated surgically using punctal plugs (temporary) or punctal cauterisation (permanent).
- Brow ptosis is treated by raising the brow
- Upper eyelid closure is assisted dynamically by surgical insertion of a lid load which is often a thin, gold plate weighing 1.2 or 1.4 grams, which is sutured inside the eyelid usually under local anaesthetic. For patients with gold allergies, a platinum chain weight can be used instead.
- The lower eyelid sag and ectropion is corrected by a canthopexy/canthoplasty, such as a lateral tarsal strip or augmented strip. This tightens and elevates the lower lid at the lateral canthus.
- The medial corner of the eyelid can be closed with a medial canthoplasty.
- In patients with severe keratitis and risk of severe loss of vision, the upper eyelid can be lowered by a levator recession in order to protect the cornea.
- Protective ptosis can be induced with an injection of Botulinum Toxin A (e.g. Boto ®, Dysport ®) into the inner surface of the eyelid.
- Rarely, the eyelids are closed using a tarsorraphy with stitches between the upper and lower lids. This is typically a temporary surgery when there is a severe keratitis.
- Watering eyes in facial palsy can be due to drying, eyelid malpoisiton or poor eyelid pump. Poor tear drainage caused by malfunctioning orbicularis muscle may require a dacryocystorhinostomy (DCR) and Jones’ Tube.
- Some patients with chronic watering eye during eating (crocodile tears) can be treated using an injection of Botulinum Toxin A into the lacrimal gland to prevent watering for an extended period of time.
Correction of Facial Asymmetry in Facial Palsy
Treatment of the appearance of the patient’s face is very important if the facial palsy does not improve spontaneously. Medical and surgical options to regain facial symmetry include:
- The eyebrows can be equalised by injecting the non-affecting forehead with Botulinum Toxin A to abolish the horizontal frown lines.
- The affected eyebrow ptosis can be elevated with a direct, pretrichial or endoscopic brow lift.
- A lateral tarsal strip (see also above) can be performed, or spacers insterted to raise the lower lids. Common spacers consist of the patient’s own ear cartilage or hard palate. At Clinica London, we also use Surederm® which is donor human collagen.
- A mid-face lift can be performed in more severe cases of facial palsy. This is usually done under general anaesthetic. Incisions are made in specific areas that allow for minimal scarring, ideally hidden with hair or natural wrinkles. Specific devices to pull the tissues upwards (threads, Endotine®, etc.) can be used, placed beneath the muscles of the face and may be reabsorbable or remain permanently.
- Filler injections with a hyaluronic acid gel (e.g. Restylane®, Perlane®) can also be used in facial palsy rehabilitation. More longer acting fillers include Sculptra® or autologous fat transfer. The filler is injected into the cheek on the affected side and the nasal labial fold on the unaffected side.