Purpose: Patients with acute paralytic lagophthalmos are at high risk for ocular surface breakdown due to exposure. External eyelid weights are a temporary solution for paralytic lagophthalmos that aim to reduce exposure and optimize blink excursion. Despite easy application and high efﬁcacy, this product is under-utilized in clinical practice with few physicians employing this treatment adjunct. Results: Ocular surface health was maintained in all patients, and overall aesthetic satisfaction was high. Conclusion: External eyelid weights are a valuable adjunct in the treatment of facial palsy but are under-utilized in clinical practice. This article highlights the beneﬁts of external eyelid weights as an accessible adjunct to restore eyelid function and maintain cosmesis. The device can be implemented without specialist involvement and adds a dimension of independence for general practitioners to manage ocular complications of facial palsy. INTRODUCTION Acute onset paralytic lagophthalmos due to facial nerve Lagophthalmos is the incomplete or defective closure of the palsy is commonly seen in the primary care setting, ophthal- eyelids. Eyelid closure and the blink reﬂex are essential for a mology practice and emergency department. With diminished healthy corneal surface, maintaining ocular surface lubrication ability to blink and close the eyelids, patients if not managed, and also as protection from a foreign body in the event of an are at high risk for exposure keratopathy, corneal surface insult. Continued corneal exposure accelerates evaporation of breakdown, ulceration and ultimately permanent vision loss. the protective tear ﬁlm and consequently patients complain of The cornea is a multifunctional tissue; it contributes a large dry irritated eyes [1, 2]. proportion of the refractive power of the eye, meaning it must The primary aetiology of lagophthalmos is facial nerve par- serve as a barrier to keep pathogens from reaching the rest of the alysis (paralytic lagophthalmos), however it can be resultant of eye, whilst maintaining transparency. The eye elects to limit local surgical error, trauma (cicatricial lagophthalmos) or during immune and inﬂammatory responses to avoid scarring and pre- sleep (nocturnal lagophthalmos). serve vision, this peculiarity is known as immune privilege, a Received: September 19, 2017. Revised: October 15, 2017. Accepted: November 2, 2017 © The Author 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx087/4824927 by Ed 'DeepDyve' Gillespie user on 16 March 2018 The role of external eyelid weights in acute facial palsy 31 phenomenon demonstrated by the cornea. This mechanism is usually effective however the drying of the tear ﬁlm can lead to small abrasions and allow external pathogens to inﬁltrate this privileged site, leading to a downward cascade of erosion and ulceration that can, if not managed, result in blindness. Diagnosing lagophthalmos in the primary care setting can be difﬁcult as one must consider and eliminate the more sinis- ter aetiologies of this condition. The most prevalent diagnosis is that of Bell’s palsy, however, as a clinical diagnosis of exclu- sion, physicians in the primary care setting with limited imme- diate access to diagnostic resources may feel uncomfortable making this judgement without further investigation [3, 4]. Referral to specialist tertiary services should always be con- sidered however many practical steps can be taken to prevent damage to the cornea during this vulnerable time. Initial management consists of intensive lubrication and ophthalmology referral. National Institute for Health and Care Excellence, Clinical Knowledge Summary (NICE CKS) manage- ment guidelines detail an evidence based approach to prescrip- Figure 1: Ideal positioning of Blinkeze external eyelid weight. tion of antiviral agents and steroids, but recommendations for eye care and secondary referral are based on expert opinion . the younger cohort of patients. Stuart Seiff at UCSF was the ﬁrst Subspecialist care for the patient with acute onset paralytic to share his experience with this treatment in 1995, however, lagophthalmos aims to optimize ocular surface lubrication and lid loading has been subsequently investigated [12, 14, 15]. guarantee corneal protection. This can be achieved by frequent Despite the easy administration and efﬁcacy, this intervention instillation of artiﬁcial tears, eyelid taping at night and external is under-utilized in the UK with few physicians employing this eyelid weights . Patients can beneﬁt from the induction of pro- treatment adjunct. tective ptosis by an injection of botulinum toxin type A into the In this article, we report a series of patients who were suc- levator palpebrae superioris muscle [7, 8], an approach usually cessfully managed with external eyelid weights and hope that reserved for patients with limited functional capacity or who are this will popularize their use in the future management of this poor surgical candidates. In cases where facial nerve recovery is condition, by a wider circle of physicians from general practi- limited, surgical interventions are adopted as follows: tarsorrha- tioners to oculoplastic surgeons. phy, lower eyelid tightening and/or implantation of gold or plat- inum weights within the upper eyelid . The implementation of facial physiotherapy to optimize neuro-muscular recovery is of CASE REPORT 1 paramount importance and should not be discounted. A 42-year-old male presented to the emergency room with The psychosocial impact should also be considered as the acute onset left facial droop, paraesthesia, otalgia and an emer- face and eyes convey emotion and patients have to immedi- gent vesicular rash on the left cheek and ear. He reported ocu- ately adjust to this dysmorphic condition, despite most cases lar irritation and epiphora. He was diagnosed with Ramsay recovering without permanent sequel . Hunt syndrome, commenced on aAciclovir, and referred to the ophthalmology service for review (Fig. 2). EXTERNAL EYELID WEIGHTS The patient was advised to use lubrication, and ﬁtted with an external eyelid weight (1.4 g) to restore eyelid functionality External eyelid weights are a temporary solution for paralytic and protect the ocular surface. Figures below depict the weight lagophthalmos that aim to restore functionality to the eyelid aiding with closure of the left upper eyelid. This would help to during the transitional rehabilitation period. The weights can improve eyelid approximation by restoring the blink response be adhered to the pretarsal skin adjacent to the sulcus and will improving cosmesis whilst preserving integrity of the cornea. hide behind the superior palpebral fold . The weights are to be attached to the upper eyelid with dou- ble sided adhesive tape provided with the kit. It is recom- CASE REPORT 2 mended that the adhesive strips are changed daily however for patients with reduced dexterity or those who will struggle to ﬁt A 72-year-old male presented with a 2-day history of unilateral the weight correctly, a tissue adhesive can be used as an alter- facial paralysis. He was referred for ocular review and manage- native with mean wear time described as 10.7 days . ment by his GP who diagnosed Bell’s palsy and initiated him on The weight should be administered to the upper eyelid with an oral steroid regimen as per NICE guidelines  (Fig. 3). the concave surface attached to the skin. The company recom- Socially, however, our patient reported that he was a carer mends placing the weight while the patient is sitting upright to his wife and would struggle with the high frequency of eye ~3 mm above the lash line. It should be centred at the junction drop instillation and taping instructions at night. On examin- of the medial and central third of the eyelid (Fig. 1), as this is ation there was left sided facial nerve palsy with a left paralytic the point of maximal levator function. Weights should be sized ectropion of the orbicularis oculi muscle noted resulting in a with optimal position inducing a ptosis of roughly 1 mm when 6 mm lagophthalmos. Bells phenomenon was present. the patient is looking straight ahead. The product is manufac- The patient reported that hisdutiesas a caregiverfor hiswife tured in various skin tones and weights [11–13]. would limit his ability to comply with frequent eye drops and The weights protect the cornea and improve dynamic lid eyelid taping at night. As such, he was prescribed an external eye- functionality and aesthetics, which are equally important in lid weight in conjunction with a reduced lubrication regimen. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx087/4824927 by Ed 'DeepDyve' Gillespie user on 16 March 2018 32 V. Sri Shanmuganathan et al. Figure 2: eyelids open and eyelids closed before and after the application of eternal eyelid weight Figure 3: eyelids open and eyelids closed before and after the application of eternal eyelid weight patient comfort by optimizing blink excursion and reducing CASE REPORT 3 exposure due to incomplete eyelid closure. A 29-year-old female was referred with a known diagnosis of We believe that the use of external lid weights has been lim- facial palsy since 2012. She was previously managed at a major ited for multiple reasons. First, there is relative paucity of litera- University Hospital with lubrication and night time taping. She ture on the use of external eyelid weights. Second, due to the presented as a new patient for routine review due to relocation possible temporary nature of facial palsy and the highly specia- nearer to our centre. On examination, punctate epithelial erosions lized sight organ that it affects, many general practitioners may were observed on the lower third of the left cornea. External eye- be hesitant to institute any form of therapy other than topical lid weights were sized and offered to this patient as an adjunct, lubrication, opting to wait for specialist input. This is unfortu- who reported that she was previously unaware of this treatment nate because specialist appointments may not be accessible to option (Fig. 4). the patient who is at risk for vision compromise. Third, it is cer- On follow up all patients were still in possession of the tainly cheaper for patients to tape their eyelids closed. It is our device and had reported using it for the initial follow-up period. experience, however, that patients suffer contact or irritative dermatitis from repeatedly taping the thin skin of the upper and lower eyelids. The paper adhesive tape affects a much larger DISCUSSION area of the sensitive periocular skin, and patients have to The primary goal in patients with acute paralytic lagophthal- change the tape daily to enable vision, further exacerbating the mos is to prevent damage to the ocular surface and improve dermatitis. Additionally, patients are often instructed to instil Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx087/4824927 by Ed 'DeepDyve' Gillespie user on 16 March 2018 The role of external eyelid weights in acute facial palsy 33 Figure 4: eyelids open and eyelids closed before and after the application of eternal eyelid weight eye ointment prior placing the tape, but this causes the tape to The majority of facial palsies except those resultant from sur- lose its adherence and patients become frustrated reducing gical transection may recover function within a year from onset compliance. Finally, there is a common misconception that an . When facial palsy is deemed to be permanent, surgical eye patch will retain moisture in the eye. Eye patches are implantation of an eyelid weight with or without lower eyelid vaulted to avoid pressure/scratching of the eye and are not air- tightening surgery is considered the gold standard treatment. tight. Since evaporative tear loss is the main aetiology of expos- However, studies report revision surgery in up to one in six ure keratopathy in patients with lagophthalmos, eye patches do patients (within 12 months) due to poor cosmesis and incomplete not help to prevent this mechanism of eye damage eyelid closure . We believe that external eyelid weights are an External eyelid weights may play a role in the management effective option for patients awaiting nerve function recovery of both temporary and permanent facial nerve palsies. NICE within the initial 12-month period. Even in patients who ultim- CKS guidelines indicate that secondary referral to ophthalmol- ately require surgical lid weight placement, delaying surgery for ogy should only be sought ‘if the cornea remains open after at least 12 months in order to ascertain any improvement may attempting to close the eyelid’ . In the acute setting, external allow accurate lid weight sizing and therefore optimization of eyelid weights can be used as an adjunct to artiﬁcial tears and ﬁnal aesthetic outcome reducing the need for revision surgery. lubricating ointment. Early prescription of external eyelid weights may reduce secondary care referral to ophthalmology Limitations in temporary acute onset paralytic lagophthalmos. Currently tarsorrhaphy is used in instances when comorbid- The external eyelid weights are generally well tolerated and no ities reduce a patient’s ability to administer drops. Given the ten- complications were reported by our patients with their use. dency for suture tarsorrhaphies to cheesewire and erode, in Contact dermatitis is a potential side effect of the adhesive addition to being cosmetically objectionable, the use of external tape, however, the area of contact is much smaller than when eyelid weights will allow patients to avoid this intervention. In using tape. Both in our cohort and in the literature there is no patients with limited manual dexterity or functional capacity, evidence of this complication . Dermatochalasis is a limita- botulinum toxin injection into the levator palpebrae superioris tion to the efﬁcacy of this product as the laxity of tarsal skin muscle can cause complete closure of the eyelid. This is often may reduce the desired action of the weight. In these patients referred to as ‘chemical tarsorrhaphy’. The limitations of this the weight may be worn closer to the lid margin sacriﬁcing practice are: (i) Lack of predictability even in expert hands. Toxin cosmesis to preserve corneal safety. Patient dexterity is another injected into this thin muscle can diffuse into the adjacent concern for effective weight placement, however, in these superior rectus muscle, which then causes the downward gaze, instances, a long-term tissue adhesive may be considered to aligning the cornea further into the area of exposure, worsening overcome this constraint . the risk of exposure keratopathy. (ii) Once the lid is successfully ptotic, the patient cannot wilfully elevate the eyelid except with Patient satisfaction a ﬁnger, which is impractical for daily function. A fully closed eye deprives patients of binocular vision and can increase risks The frequency of artiﬁcial tear drop instillation required to for falls and accidents. In contrast, the eyelid weight is designed lubricate an eye that does not blink is intense. It is widely to permit use of the eye while simulating normal blink reﬂexes reported that adherence to medication is sub optimal in the to protect the ocular surface. (iii) The effect of botulinum toxin general population with rates inversely proportional to age. lasts ~3 months. If facial nerve function recovers earlier than Reduced compliance with eye drop instillation is linked to that, patients are still left with a closed eyelid. If facial nerve memory and dexterity [18,19]. The external eyelid weights have function does not recover within 3 months, repeat injections been proven to reduce the reliance on artiﬁcial tear drops when would be necessary, incurring further costs. used as adjunctive treatment . Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx087/4824927 by Ed 'DeepDyve' Gillespie user on 16 March 2018 34 V. Sri Shanmuganathan et al. 3. Vakharia K. Bell’s palsy. Facial Plast Surg Clin North Am 2016; Functionality and aesthetics 24:1–10. External eyelid weights are the only temporary treatment for 4. Grzybowski A, Kaufman MH. Sir Charles Bell (1774-1842): facial palsy that reinstate the natural mechanism of eyelid contributions to neuro-ophthalmology. Acta Ophthalmol closure. As shown in the images above, the weight restores the Scand 2007;85:897–901. movement of the eyelid and is matched to skin colour, hiding 5. Summaries NCK. Management of Bell’s Palsy. 2012. http://cks. within the tarsal crease to provide an acceptable cosmetic out- nice.org.uk/bells-palsy#!scenario (accessed 26 January 2016). come. Restoration of cosmesis and functionality of the eyelid 6. Sohrab M, Abugo U, Grant M, Merbs S. Management of the while protecting the cornea is achievable with this product eye in facial paralysis. Facial Plast Surg 2015;31:140–4. reducing the social impact of this debilitating condition. 7. Rahman I, Sadiq SA. Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol 2007;52:121–44. Cost 8. Ellis MF, Daniell M. An evaluation of the safety and efﬁcacy The current cost for this device is ~£150 for the weight and of botulinum toxin type A (BOTOX) when used to produce a adhesive strips. As mentioned above, timely prescription in the protective ptosis. Clin Experiment Ophthalmol 2001;29:394–9. primary care or emergency room setting may serve to reduce 9. Leatherbarrow B, Collin JR. Eyelid surgery in facial palsy. Eye the referral burden to the oculoplastic service for temporary (Lond) 1991;5:585–90. palsies and during the initial observation period, offsetting the 10. Walker DT, Hallam MJ, Ni Mhurchadha S, McCabe P, Nduka C. initial cost burden. The psychosocial impact of facial palsy: our experience in one hundred and twenty six patients. Clin Otolaryngol 2012; 37:474–7. CONCLUSION 11. Zwick OM, Seiff SR. Supportive care of facial nerve palsy In summary, external eyelid weights are a valuable adjunct in with temporary external eyelid weights. Optometry 2006;77: the treatment of facial palsies. The device restores eyelid func- 340–2. tion while maintaining cosmesis, thereby reducing the devas- 12. Seiff SR, Boerner M, Carter SR. Treatment of facial palsies tating psychosocial impact whilst protecting the cornea. Early with external eyelid weights. Am J Ophthalmol 1995;120:652–7. prescription will bridge the gap in non-resolving palsy, delaying 13. Corporation M Blinkeze External Lid Weights. 2004. http:// deﬁnitive surgery to allow for more accurate assessment of www.meddev-corp.com/1%20product/Eyelid%20Closure% eyelid function and surgical planning. 20Products/External%20Weights.2.htm (accessed 7 October This article aims to highlight the simplicity of use and applica- 2015). tion. The device can be implemented without specialist oculo- 14. Hesse S, Werner C, Melzer I, Waldner A, Bardeleben A. plastic involvement and would add a dimension of independence External lid loading for the temporary treatment of paresis of to the management of facial palsy in the primary care setting. the M. orbicularis oculi: a case report. Arch Phys Med Rehabil 2011;92:1333–5. CONFLICT OF INTEREST STATEMENT 15. Müller-Jensen G, Müller-Jensen K. [New methods for the treatment of loss of eyelid closure in reversible facial par- This research received no speciﬁc grant from any funding agency in the public, commercial or not-for-proﬁt sectors. alysis]. Nervenarzt 1996;67:667–71. 16. Portelinha J, Passarinho MP, Costa JM. Neuro-ophthalmological approach to facial nerve palsy. Saudi J Ophthalmol 2015; CONSENT 29:39–47. All patients included in this case series consented for their data 17. Bladen JC, Norris JH, Malhotra R. Indications and outcomes and images to be used for publication and/or presentation. for revision of gold weight implants in upper eyelid loading. Br J Ophthalmol 2012;96:485–9. REFERENCES 18. Fischer MA, Stedman MR, Lii J, Vogeli C, Shrank WH, 1. Pereira MV, Glória AL. Lagophthalmos. Semin Ophthalmol Brookhart MA, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med 2010;25:72–8. 2. Shepler TR, Seiff SR. Use of isobutyl cyanoacrylate tissue 2010;25:284–90. 19. Kholdebarin R, Campbell RJ, Jin YP, Buys YM. Multicenter adhesive to stabilize external eyelid weights in temporary treatment of facial palsies. Ophthal Plast Reconstr Surg 2001; study of compliance and drop administration in glaucoma. Can J Ophthalmol 2008;43:454–61. 17:169–73. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/1/omx087/4824927 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Oxford Medical Case Reports – Oxford University Press
Published: Jan 1, 2018
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