Fac-nerve-eye-slides-060329 - Facial Nerve Paralysis:...

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Unformatted text preview: Facial Nerve Paralysis: Management of the Eye Management Sam J. Cunningham, MD, PhD David C. Teller, MD University of Texas Medical Branch Grand Rounds Presentation March 29, 2006 Facial Nerve Paralysis: Management of the Eye Management Introduction Anatomy Options Discussion of Literature Introduction-Facial Nerve Paralysis Introduction-Facial Functional and cosmetic problems Upper lid fails to drop down and close Lower lid loses tone and sags downward – May evert leading to ectropion Produces lagophthalmos and consequent corneal Produces exposure. exposure. Interruption of the tear film Leads to drying of cornea, – Ocular discomfort – Corneal ulcers – Infection – Perforation Introduction-Facial Nerve Paralysis Introduction-Facial Increased risk of complications: – Poor Bell phenomenon – Corneal anesthesia – Pre-existing dry eye Normal Eye Closure Normal Contraction of the obicularis oculi Contraction results in lowering the upper lid results Elevation of the lower lid Elevation contributes minimally Anatomy Anatomy Eyelid functions – Protect eye (light, injury, desiccation) – Tear production and distribution Extremely thin skin (upper > lower) Skin Skin – Little subcutaneous fat – Adherent over the tarsus (levator aponeurosis) Anatomy Anatomy Anatomy Anatomy Horizontal length – 30 mm Palpebral fissure – 10 mm Margin reflex distance – Number of millimeters from Number the corneal light reflex to the lid margin lid – Upper lid – 4 to 5 mm (rests Upper slightly below limbus) slightly – Lower lid – 5 mm (rests at the Lower lower limbus lower Anatomy Anatomy Tarsus – Dense, fibrous tissue – Contour and skeleton – Contain meibomian Contain glands glands – Length – 25 mm – Thickness – 1 mm – Height Upper plate – 10 Upper mm mm Lower plate – 4 Lower mm mm Anatomy – Muscles Protractor-Facial nerve – Orbicularis Retractors-Oculomotor – Levator – Müller’s Anatomy: Upper and lower lids Anatomy: Orbicularis Oculi Muscle Orbicularis Anatomy: Obicularis Anatomy: Levator palpebral superioris Levator and Müller’s muscle üller’s Lower Lid Anatomy Lower Anatomy Anatomy Orbital Septum – Fascial barrier – Underlies posterior Underlies orbicularis fascia orbicularis – Defines anterior extent Defines of orbit and posterior extent of eyelid extent Anatomy Anatomy Canthal tendons – Extensions of preseptal & pretarsal orbicularis – Lateral slightly above medial – Lateral tendon attaches to Whitnall’s tubercle Lateral 1.5 cm posterior to orbital rim 1.5 – Medial tendon complex, important for lacrimal Medial pump function pump Medial Canthal Tendon Medial Lateral Canthal Tendon Lateral Canthal Tendons Canthal Lacrimal System Lacrimal Lacrimal Excretory Pump Lacrimal Facial Nerve Paralysis: Management of the Eye Management Initial treatment – Ophthalmic drops/ointments (Jelks 1979) – Protective taping, occlusive moisture chambers, Protective soft contact lenses, scleral shields (Goren and soft Clemis 1973) Clemis – Tarsorrhaphy suture Majority of patients require definitive Majority surgical treatment to correct chronic impairment impairment Facial Nerve Paralysis: Management of the Eye Management Surgical options include: – Temporalis muscle transfer (Gillies) Temporalis (Gillies) – Encircling the upper and lower eyelids with Encircling silicone or fascia lata (Freeman) (Freeman) – Palpebral springs (Levine,May) Palpebral (Levine,May) – Tarsorrhaphy (McLaughlin) Tarsorrhaphy (McLaughlin) – Lid loading (Sheehan, others) (Sheehan, – Combinations Combinations Surgical Procedures Surgical Palpebral Spring – Advantages Less visible – Disadvantages Technically difficult Higher risk of extrusion Tarsorrhaphy Tarsorrhaphy Poor cosmesis Decreased peripheral Decreased vision vision Surgical Procedures Surgical Lower lid shortening – Wedge excision with Wedge lateral canthopexy lateral – Used in combination with Used gold weight implantation gold Lid Loading Lid Early technique – Incision in the supratarsal crease – Subcutaneous pocket Subcutaneous – Insert weight – Close skin Lid Loading-Early Technique Lid Stainless steel – – – High profile Migratory High rate of extrusion Gold – – – – – – Higher density - more weight in same size Malleable - conforms to the globe-lower profile Lower reactivity Reversible Migratory High rate of extrusion Gold Weight Gold Surgical Procedures Surgical Gold weight implantplaced beneath levator placed aponeurosis aponeurosis – Advantages Technically straightforward Consistent – Disadvantages-less than Disadvantages-less with previous technique with Less Visibility Less Extrusion Less Mobility Gold Weight Gold Gold Weight Placement Gold Combination of Gold Weight and Lower Lid Shortening Lower Combination of Gold Weight and Lower Lid Shortening Lower Platinum Chain Platinum Relevant Literature Kinney et al: “Oculoplastic Surgical Kinney Techniques for Protection of the Eye in Facial Nerve Paralysis” Facial – Described an algorhythm for surgical Described management of corneal exposure 2nd to CNVII management paralysis paralysis – Auricular cartilage vs lateral canthotomy vs Auricular dissection of suborbicularis oculi fat pad (SOOF) vs brow elevation………. Ocular Management Paradigm Ocular Literature Literature Snyder et al: “Early vs Late Gold Weight Snyder Implantation for Rehabilitation of the Paralyzed Eyelid” Paralyzed – Evaluated outcomes and complications of early Evaluated (<30 days) vs late (>30 days) gold weight implantation implantation – 89.2% achieved satisfactory lid closure – Statistically similar lid closure and complication Statistically rates rates Literature Literature Foda: “Surgical Management of Foda: Lagophthalmos in Patients with Facial Palsy” Palsy” – Gold weight in combination with canthoplasty – Complete correction of lagophthalmos and Complete ectropion with resolution of pre op symptoms in 92.5% of patients. 92.5% Literature Literature Jobe: 2080 procedures with gold weight implants. – Only 3% patients with reported complications Harrisberg et al: 103 patients with gold weight Harrisberg implants implants – 46 had weights removed 46 78% due to facial nerve recovery 22% due to cosmetic dissatisfaction, implant 22% becoming too superficial, migration, partial extrusion (implanted into prefashioned soft tissue pocket in the preseptal space) tissue Literature Literature Chepeha et al: 16 patients Chepeha – Lagophthalmos: pre op 7.5mm, post op 0.5mm – Corneal coverage: pre op 73%, post op 100% – High patient satisfaction – No extrusions Conclusions Conclusions Gold weight implants safe and effective Early implantation-reversible Excellent results when used in combination Excellent with lower lid shortening with Bibliography Bibliography Foda, H Surgical Management of Lagophthalmos in Patients with Facial Nerve Palsy. American Foda, Journal of Otolaryngolgoy Vol 20, No6, 1999. Journal Jobe, R A Technique for lid loading in the management of lagophthalmos of facial palsy. Plast Jobe, Reconstruct Surg. 53; 1974 Reconstruct Tremolada, C Temporal galeal fascia cover of custom-made gold lid weights for correction of Tremolada, paralytic lagophthalmos: long term evaluation of an improved technique. paralytic Chang, L A useful augmented lateral tarsal strip tarsorrhaphy for paralytic ectropion. Chang, Ophthalmology. Vol113, No 1. 2006. Ophthalmology. Harrisberg, B Long term outcome of gold eyelid weights in patients with facial nerve palsy. Otology Harrisberg, and Neurotoloty. 22, 2001. and Chepeha, D Prospective evaluation of eyelid function with gold weight implants and lower eyelid Chepeha, shortening for facial paralysis. Acrh of Oto Head and Neck Surg. 127(3) 2001. shortening Kinney S Oculoplastic surgical techniques for protection of the eye in facial nerve paralysis. Am Jour Kinney Otology. 21: 2001. Otology. Snyder M Early vs late gold weight implantation for rehabilitation of the paralyzed eyelid. Snyder Laryngoscope. 111: 2001 Laryngoscope. Lavy J Gold weight implants in the management of lagophthalmos in facial palsy. Clinical Lavy Otolaryngology. 29:2004 Otolaryngology. Caesar R Upper lid loading with gold weights in paralytic lagophthalmos: a modified technique to Caesar maximize the long-term functional and cosmetic success. Orbit 23 (1). 2004. maximize Berghaus, A The platinum chain: a new upper-lid implant for facial palsy. Arch Facial Plast Surg vol Berghaus, 5.2003. 5.2003. Kao C Retrograde weight implantation for correction of lagophthalmos. Laryngoscope. 114:2004. ...
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