Lagophthalmos

In this article:

• Treatment options for lagophthalmos
• Medical
• Acupuncture
• Surgical
• Tarsorrhaphy
• Gold/Platinum Weight Implantation
• Upper Eyelid Retraction and Levator Recession
• Lower Eyelid Tightening and Elevation
• Cornea transplant
• Ancillary Surgical Procedures
• References

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Treatment options for lagophthalmos

Medical

Artificial tears without preservatives can be administered frequently in order to improve the patient’s tear film. The ointment can be applied at night time or during the day if there is severe corneal exposure. Taping of the eyelids at night can offer additional ocular surface protection without resorting to surgery.

There are also moisture chamber-type glasses which can aid in maintaining a stable tear film and improve symptoms.

The volumizing hyaluronic acid gel has been used for tissue expansion for immediate management of cicatricial ectropion in cases of lagophthalmos e.g. congenital ichthyosis.

Once the cornea is protected, longer term planning for eyelid and facial rehabilitation may take place.

A repeated subconjunctival injection of triamcinolone is an effective and relatively safe treatment for upper lid retraction due to thyroid-associated ophthalmopathy. This is related to the anti-inflammation effect of the medicine and the levator thickness can become thinner. Patients must be monitored regularly for recurrences and side effects.

Acupuncture

Acupuncture is a low-risk and safe therapeutic method in various diseases, including Bell’s palsy, and there is no evidence of any deleterious effects. It is, therefore, safely used as a complementary treatment in both children and adults. Electroacupuncture is particularly widely used in the treatment of Bell’s palsy.

Owing to the importance of facial symmetry in terms of perceived attractiveness and its effect on interpersonal communication, patients who develop sequelae may receive electroacupuncture therapy to bring about the best possible and earliest improvement and to halt complications.

Surgical

Correcting upper eyelid function involves facilitating the component of eye closure that is in the same direction as gravity and is, therefore, less complicated and favorable outcomes than correction of lower lid. Aesthetic aspects should be considered to correct the asymmetry caused by facial palsy.

Lower eyelid function involves a force that opposes gravity for eye closure, which makes correction of lower eyelid ectropion more challenging than surgery for the upper eyelid, particularly in terms of effecting a sustained correction. Initially, proper ophthalmic evaluation is required, including identifying the chronicity and severity of ectropion.

Also, it is important to determine whether or not lateral canthoplasty is necessary. The lateral tarsal strip procedure is commonly used for lower lid correction. However, effective lower lid correction can be achieved with better cosmesis when extensive supporting techniques are applied, including those involving cheek tissue.

Tarsorrhaphy

When there is corneal exposure and recovery is expected within a matter of weeks, a temporary tarsorrhaphy can be a good option. In the majority of cases, the cornea can be protected adequately by closing the lateral one-third of the eyelids. A small opening should remain so that the cornea can be continuously assessed and required topical medications can be administered. Loosening of the sutures can occur over time, resulting in inadequate ocular surface protection. Complications include trichiasis and poor cosmesis from scarring.

Gold/Platinum Weight Implantation

Implantable devices are commonly used to restore dynamic lid closure. Reinforcement of eyelid weight allows the upper eyelid to close with gravity. Implants are composed of 99.99% pure gold, and their weights range from 0.6 to 1.8 g.

Platinum has a higher density which allows to have thinner implant that is less visible and does not cause discomfort while the eye is open. It is also hypoallergenic compared to gold, which cause significantly less problems with contact allergic dermatitis and decreased rates of extrusion.

Upper Eyelid Retraction and Levator Recession

Retraction of the upper eyelid is common in patients with thyroid disease. in such situation patient can have recession surgery of the upper eyelid retractor muscles (levator palpebrae superioris and Müller’s muscles).

Pentagonal wedge resection to release a retracted structure, fat redistribution to prevent readhesion, and full-thickness skin grafting for enough amount of skin to regain upper eyelid function is useful for scar release and lagophthalmos following crushing injuries of the upper eyelid.

Postsurgical lid shortening after upper lid blepharoplasty can be treated with full-thickness skin grafts or advancement flaps. For cicatricial lagophthalmos scar band releases and tarsal-sharing procedures can be used.

Modified silicone sling assisted temporalis muscle transfer can be used in the management of paralytic lagophthalmos

Lower Eyelid Tightening and Elevation

Lid tightening procedures, such as lateral tarsal strip, designed to improve the esthetics and decrease drying of the cornea. Lower eyelid elevation with retractor muscle recession can be an option for lower lid significant lowering.

A spacing graft sutured in place to achieve further elevation. The grafts can be taken from ear, nose or hard palate. For a full-thickness involvement skin graft and/or mucous membrane graft could be used.

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Cornea transplant

Prolonged corneal exposure eventually leads to significant changes in that protective eye layer. Keratitis is an inflammation of the cornea that develops due to absence of the tear on the open surface. Cornea ulcer is a significant complication of the long-standing untreated lagophthalmos.

The cornea is a five-layered structure that provides the majority of the total refractive power of the eye. In the past, penetrating keratoplasty (PK) had been the gold standard surgical treatment of corneal diseases for any layer, including diseases of the endothelium.

With the improvement in technology and innovation over the last two decades, endothelial keratoplasty (EK) techniques involving transplantation of corneal components have been deployed to treat these diseases.

When compared to PK, EK introduces less foreign antigens, has improved visual recovery and outcomes, minimizes astigmatism, has less risk of dehiscence, and results in better globe stability.

Ancillary Surgical Procedures

Severe lagophthalmos secondary to facial nerve paralysis may require midface elevation. This can be achieved with a variety of techniques, such as using autogenous fascia slings. Other approaches to reanimate the face include temporalis muscle transposition, nerve grafts, palpebral springs, suborbicularis oculi fat lifts, and soft tissue repositioning.

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References

Upper eyelid platinum weight placement for the treatment of paralytic lagophthalmos: A new plane between the inner septum and the levator aponeurosis. Oh TS, Min K, Song SY, Choi JW, Koh KS.Arch Plast Surg. 2018 May;45(3):222-228. doi: 10.5999/aps.2017.01599. Epub 2018 May 15.PMID: 29788690 Free PMC article.

Modified silicone sling assisted temporalis muscle transfer in the management of lagophthalmos. Gupta RC, Kushwaha RN, Budhiraja I, Gupta P, Singh P.Indian J Ophthalmol. 2014 Feb;62(2):176-9. doi: 10.4103/0301-4738.128629.PMID: 24618488 Free PMC article.

The Efficacy of Acupuncture in the Treatment of Bell‘sPalsy Sequelae. Öksüz CE, Kalaycıoğlu A, Uzun Ö, Kalkışım ŞN, Zihni NB, Yıldırım A, Boz C.J Acupunct Meridian Stud. 2019 Aug;12(4):122-130. doi: 10.1016/j.jams.2019.03.001. Epub 2019 Apr 1.PMID: 30946987 Free article. Clinical Trial.

Neuro-ophthalmological approach to facial nerve palsy. Portelinha J, Passarinho MP, Costa JM.Saudi J Ophthalmol. 2015 Jan-Mar;29(1):39-47. doi: 10.1016/j.sjopt.2014.09.009. Epub 2014 Sep 28.PMID: 25859138 Free PMC article. Review.

Long-term effect of triamcinolone acetonide in the treatment of upper lid retraction with thyroid associated ophthalmopathy. Xu DD, Chen Y, Xu HY, Li H, Zhang ZH, Liu YH.Int J Ophthalmol. 2018 Aug 18;11(8):1290-1295. doi: 10.18240/ijo.2018.08.07. eCollection 2018.PMID: 30140631 Free PMC article.

Litwin AS, Kalantzis G, Drimtzias E, Hamada S, Chang B, Malhotra R. Nonsurgical treatment of congenital ichthyosis cicatricial ectropion and eyelid retraction using Restylane hyaluronic acid. Br J Dermatol. 2015 Aug;173(2):601-3. [PubMed]

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Chung CM, Tak SW, Lim H, Cho SH, Lee JW. Early cicatricial lagophthalmos release with pentagonal wedge resection of the scar, fat redistribution, and full-thickness skin grafting. Arch Craniofac Surg. 2020 Feb;21(1):49-52. [PMC free article] [PubMed]

Kwon KY, Jang SY, Yoon JS. Long-Term Outcome of Combined Lateral Tarsal Strip With Temporal Permanent Tarsorrhaphy for Correction of Paralytic Ectropion Caused By Facial Nerve Palsy. J Craniofac Surg. 2015 Jul;26(5):e409-12. [PubMed]

Friedhofer H, Coltro PS, Vassiliadis AH, Nigro MV, Saito FL, Moura T, Faria JC, Ferreira MC. Alternative surgical treatment of paralytic lagophthalmos using autogenic cartilage grafts and canthopexy. Ann Plast Surg. 2013 Aug;71(2):135-9. [PubMed]

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