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Prospective Evaluation of Eyelid Function With Gold Weight Implant and Lower Eyelid Shortening for Facial Paralysis
Douglas B. Chepeha, MD, MSPH;
John Yoo, MD;
Catherine Birt, MD;
Ralph W. Gilbert, MD;
Joseph Chen, MD
Arch Otolaryngol Head Neck Surg. 2001;127:299-303.
ABSTRACT
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Objectives To assess which signs and symptoms were relieved by gold weight implantation
and which signs and symptoms persisted.
Design Prospective observational cohort.
Setting Tertiary care neurotology and oncology center.
Patients Sixteen (4 males and 12 females) consecutive patients whose average
age was 56 years (age range, 31-76 years). Inclusion criteria were gold weight
implant, lagophthalmos of 2 mm or more, and a House-Brackmann score of 3 or
less at the completion of follow-up. Mean follow-up was 13 months.
Interventions Each patient received a gold weight implant. Six of these patients underwent
a lower eyelid procedure.
Main Outcome Measures Surgical complications, static and dynamic lagophthalmos, static and
dynamic corneal coverage, visual acuity, keratitis, topical treatment, and
patient satisfaction.
Results There were no extrusions. The preoperative mean lagophthalmos was 7.5
mm and the postoperative mean was 0.5 mm, (P<.001).
Corneal coverage with eye closure before implantation was 73% and after implantation
was 100%, (P<.001). Corneal coverage with normal
(reflex) blink was less than 50% in 9 of 14 patients. When wearing correction,
no patients had 20/20 visual acuity. The mean patient satisfaction score before
the procedure was 3.5 and after was 7.1, (P<.001).
Patient satisfaction was most closely related to visual acuity. The relationship
was linear and statistically significant (P<.04).
Conclusions Gold weight implantation provides significant reduction in lagophthalmos
and significant improvement in corneal coverage. But owing to delayed closure
time and disrupted tear film, irritation may persist. As a result, some patients
require ongoing topical treatment of the eye, which can compromise visual
acuity.
INTRODUCTION
MAINTAINING a comfortable eye in which the cornea is protected and visual
acuity is normal is the goal for patients who have lagophthalmos secondary
to facial nerve paresis or paralysis. Rehabilitation of these patients is
difficult owing to loss of the dynamic activity of the orbicularis oculi.
As a result of the impaired orbicularis function, this group of patients is
prone to exposure keratitis, epiphora (depending on the function of the lacrimal
gland), and impaired vision due to a disrupted tear film.
Gold weight implantation has become the most commonly used technique
for rehabilitation of the eye in patients with facial nerve paralysis. Many
published studies have effectively developed the technique and indications
for insertion and have established the gold weight implant as a safe and reliable
procedure.1, 2, 3, 4, 5, 6, 7, 8, 9, 10
It has been shown to effectively reduce lagophthalmos, protect the cornea,
and improve cosmesis, while having a low extrusion rate.
Although previous literature has established that the gold weight implant
with lower eyelid shortening procedures has significantly improved the treatment
of lagophthalmos secondary to facial nerve paralysis, patients continue to
be symptomatic and are not entirely satisfied. Our objective was to assess
which signs and symptoms were relieved by gold weight implantation and which
signs and symptoms persisted. We believe that the passive nature of the implant
was at least one factor that led to some of our patients' difficulties. To
determine which signs and symptoms were persistent after gold weight implantation,
we performed a longitudinal study and correlated various measures of eyelid
function to patient satisfaction. The results of this observational study
could be used to improve the rehabilitation of the eyelids in patients suffering
from paretic lagophthalmos.
PATIENTS, MATERIALS, AND METHODS
This was a prospective observational study of a cohort of 16 consecutive
patients who had a gold weight implant. There were 4 male and 12 female patients
whose average age was 56 years (age range, 31-76 years). One woman died before
follow-up could be completed, and 1 patient would only allow a telephone evaluation
after her procedure. The results are reported based on a cohort of 15 patients.
Eleven of the 15 patients had a resected acoustic neuroma. The remaining
4 patients had neurofibromatosis 2 (unresected), meningioma, cholesteatoma,
and a parotid malignant neoplasm. Eleven of the patients had a total facial
nerve defect, and each of these patients underwent a facial rehabilitation
procedure in addition to the gold weight implant. Inclusion criteria were
as follows: gold weight implant, lagophthalmos of 2 mm or more, and a House-Brackmann
score of 3 or less at the completion of follow-up.
The cohort was followed up for a mean of 13 months (range, 7-26 months).
The mean time from extirpation (or from the reanimation procedure, if done)
was 43 months (range, 0-15.6 years). Institutional policy on the study of
human subjects was followed.
The mean mass of the gold weight was 1.3 g (range, 1.0-1.4 g). The approach
was through a supratarsal crease incision. The weight was placed over the
tarsus as inferiorly as possible and centered over the midpupillary line.
It was fixed in place with three 6.0 polypropylene (Prolene) sutures on a
taper needle.
Six patients had an additional procedure to correct ectropion. Of the
6 patients, 5 had a lower eyelid tightening procedure that consisted of a
tarsoconjunctival wedge excision. The overlying skin and orbicularis flap
was not excised, rather, it was redraped and advanced laterally in a lateral
orbital crease. The sixth patient had a flexor tendon sling performed prior
to referral. We were conservative in deciding to do a lower eyelid procedure.
We did not quantify the amount of eyelid laxity prior to a lower eyelid tightening
procedure. The procedure was performed in those patients who had ectropion
of their lower eyelid, who had epiphora, and/or whom we believed would not
attain a full reduction of their lagophthalmos with the gold weight implant.
As this was an observational study, many outcome variables related to eye
function were collected (Table 1).
UPPER EYELID ASSESSMENT
Lagophthalmos was assessed with the patient's best eye closure and was
measured in millimeters. Corneal coverage was the patient's best corneal coverage
judged in percentages with 0%, 25%, 50%, 75%, 90%, and 100% cutoff points.
Corneal coverage with normal (reflex) blink was assessed at the beginning
of the interview while the patient was being asked other questions and was,
therefore, less self-conscious of their eye. The amount of corneal coverage
with normal (reflex) blink was judged in percentages using the previously
mentioned cutoff points. Delay in voluntary closure was assessed by asking
the patient to close the eye and then using a stopwatch to time how long it
took to attain best closure. Corneal coverage with normal (reflex) blink and
delay in voluntary closure were only measured after implantation.
LOWER EYELID ASSESSMENT
Epiphora was subjectively assessed as present or absent by asking the
patients whether they had difficulty with tearing of the eye while indoors.
Ectropion was assessed as absent, slight out turn, or conjunctival show.
GENERAL COMFORT AND FUNCTION
Eye irritation was assessed by asking the patient, how many days a month
does your eye feel irritated? Conjunctivitis was assessed by judging for the
presence or absence of conjunctival hyperemia. Superficial punctate keratitis
was assessed by an ophthalmologist (C.B.) using a slitlamp at the final visit.
At the final visit, visual acuity was assessed with a Snellen chart while
patients were wearing their corrective lenses at the final visit. In an attempt
to prevent patients from preparing their eye, they were not informed as to
when they would have their visual acuity tested.
SUBJECTIVE ASSESSMENT
Before and after implantation each patient was asked the question, how
would you rate your overall satisfaction with your right/left eye? This was
to be answered on a scale of 1 to 10, with 1 being the worst and 10 being
the best. Cosmetic assessment was made by asking the patients whether they
were satisfied or dissatisfied with the appearance of the implant. Finally,
the patients were asked to comment about any other difficulties they were
having with the implant.
RESULTS
Overall there was an extremely low complication rate, the procedure
was effective, and the level of patient satisfaction was high despite some
lingering problems with visual acuity. There were no implant extrusions, but
there was one minor complication: a scleral injection with a combination of
1% lidocaine hydrochloride and 1:100 000 epinephrine that was immediately
identified. The procedure was terminated, there were no sequelae, and the
patient received the implant successfully at a later date. As expected, lagophthalmos
was improved and corneal exposure with eye closure was reduced. The preoperative
mean of lagophthalmos was 7.5 mm and the postoperative mean was 0.5 mm (P<.001, power 99%) (Figure 1). Corneal coverage with eye closure before implantation
was 73% and after implantation was 100% (P<.001,
power 99%). Visual acuity was impaired in our cohort despite successful gold
weight implantation. No patients had 20/20 visual acuity, presumably secondary
to a disrupted tear film and/or topical medication. The patients' overall
satisfaction with the implant was high as assessed by a subjective rating
scale. The mean satisfaction score before the surgical procedure was 3.5 and
after the surgical procedure was 7.1 (P<.001,
power 99%) (Figure 2). Patient satisfaction
was most closely related to visual acuity. The relationship was linear and
statistically significant (P<.04) (Figure 3). Despite a statistically significant overall improvement
in satisfaction, 3 of the 15 patients were dissatisfied with the cosmetic
result. A relationship was explored between the subjective rating scale and
nerve deficit, number of days of eye irritation per month, and corneal coverage
with normal (reflex) blink. None were statistically significant. The cohort
was too small to explore multivariable relationships.
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Figure 1. Frequency plot demonstrating improvement
in lagophthalmos with gold weight implant.
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Figure 2. Frequency plot demonstrating the
improvement in patient satisfaction with gold weight implant.
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Figure 3. Scatterplot demonstrating decreasing
patient satisfaction with decreasing corrected visual acuity in a potentially
bimodal population.
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Dynamic measures of upper eyelid function revealed some of the shortcomings
of the gold weight implant. The upper eyelid has a mean closure time of 1.1
seconds (range, 0-3 seconds) (Figure 4). Corneal coverage with normal (reflex) blink was equal to or less than 50%
in 9 of 14 patients (Figure 5).
These measures suggest that during normal daily blinking, there is substantially
reduced corneal coverage with a gold weight implant when compared with an
eye with an intact facial nerve.
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Figure 4. Frequency plot demonstrating the
delay of voluntary eyelid closure after gold weight implantation.
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Figure 5. Frequency plot demonstrating the
lack of corneal coverage with normal (reflux) blink after gold weight implantation.
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Despite the reduced dynamic function of the gold weight implant, only
2 of the 15 patients had superficial punctate keratitis greater than 1+. The
amount of eye irritation varied widely. The mean number of days of eye irritation
per month was 10, but 5 patients experienced no irritation, while 4 patients
suffered constant irritation. Although a relationship between eye irritation
with trigeminal function, facial nerve function, House-Brachmann score, superficial
punctate keratitis, and subjective satisfaction score was expected, no significant
relationship was present. There was a significant linear relationship between
eye irritation and corneal coverage with normal (reflex) blink (P = .008), which may suggest that the dynamic shortcomings of the gold
weight implant are important enough to influence patient symptoms (Figure 6).
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Figure 6. Scatterplot demonstrating decreasing
eye irritation with increasing corneal coverage with reflex blink.
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Most of the patients required topical treatment at the completion of
the study. Thirteen of the 15 patients were able to decrease the amount of
tears and lacrilube they were using after gold weight implantation. Only 1
patient was able to discontinue all local measures. Two patients still required
morning and evening lacrilube, and 4 patients frequently used mechanical closure.
As part of the subjective assessment, the patients were asked to comment
on any other difficulties they were having with their eye. Many found that
wearing glasses outside was a necessity, especially on windy days. Any of
the patients who did a significant amount of reading found that their upper
eyelid became heavy and obscured their vision. Also, retaining a driver's
license was difficult owing to the impaired visual acuity. One young patient
was unable to retain a driver's license because of the inability to pass the
visual portion of the examination.
COMMENT
The objective of this study was to assess which signs and symptoms were
relieved by gold weight implantation and which signs and symptoms persisted.
We also sought to determine whether these various measures of eyelid function
correlated with patient satisfaction. The cohort of patients in this study
were prospectively followed up and represented a group suffering from chronic
facial paralysis whose recovery was no better than a House-Brackmann score
of 3.
This study shows that gold weight implants in concert with lower eyelid
tightening procedures are effective in relieving lagophthalmos and improving
corneal coverage. Unfortunately, it also reveals several shortcomings, which
include delay in upper eyelid closure and incomplete corneal coverage with
normal (reflex) blink. By extrapolation, these shortcomings in eyelid function
should lead to increased corneal exposure when compared with eyes with eyelids
that have an intact facial nerve. We found that two thirds of the patients
continued to suffer from eye irritation. Furthermore, we were able to demonstrate
a trend toward a relationship between eye irritation and corneal coverage
with normal (reflex) blink. To our knowledge, there are no previous reports
that show a relationship between subjective symptoms (eye irritation) and
dynamic measure of eyelid function (normal reflex) blink. A previous report
retrospectively examined subjective measures of patient outcome with a questionnaire.11 It yielded thought-provoking data on difficulties
with eyelid function after gold weight implantation, but, unfortunately, the
data were marred by a high extrusion rate secondary to not suturing the implants
in position.
Our study also found that patient satisfaction after implantation correlates
with postimplantation visual acuity. Patient satisfaction as assessed by a
Likertlike scale of 1 to 10 shows significant improvement after gold weight
implantation, and overall patients were pleased, but with a mean score of
7.1 from a possible 10 there was still room for improvement. The inability
of the gold weight to normalize visual acuity was presumably secondary to
a disrupted tear film and/or the continued use of topical eye care for irritation.
It is likely that the delay in closure and incomplete corneal coverage with
normal (reflex) blink is in part responsible for these difficulties with visual
acuity and the ongoing need for ongoing eye care. Other studies have evaluated
visual acuity in patients with gold weight implants who have had a similar
surgical approach.12 These studies also show
improvement in visual acuity, but incomplete normalization of visual acuity
after gold weight implantation.
Clearly, incomplete normalization of visual acuity is a major problem
in patients after gold weight implantation as assessed by both objective and
subjective measures. The difficulty with visual acuity is likely rooted in
the inability of patients with gold weight implants to completely close the
eye with a normal (reflex) blink. Procedures or implants focused on improving
the speed of closure but retaining the safety of gold weight implantation
need to be explored. A prospective study13
combining superior and inferior mullerectomy with gold weight implants has
shown encouraging results by improving involuntary closure. Unfortunately,
in this study, the mullerectomy was not uniformly applied, some of the patients
recovered facial nerve function, and ptosis was a problem in some of the patients
owing to heavy gold weights. Although difficult to prove, we believe that
some of our patients had difficulties owing to levator spasm. Mullerectomy
may be one way to approach this problem.
CONCLUSIONS
Gold weight implantation for rehabilitation of the eye in the patient
with facial nerve paralysis is safe and reliable. It provides significant
reduction in lagophthalmos and significant improvement in corneal coverage.
As assessed by a subjective rating scale, patients have a significant amount
of improvement. In this patient population, improvements still need to be
made with respect to the normal (reflex) blink. Owing to delayed closure time
and incomplete corneal coverage with the normal (reflex) blink, a disrupted
tear film and eye irritation may persist. As a result, some patients require
ongoing topical treatment of the eye, which can compromise visual acuity.
The disruption in visual acuity is subjectively the most significant problem
for patients after gold weight implantation. Modifications in the surgical
approach or alterations in the implant should be considered to improve the
dynamic function of the eyelid in patients with facial nerve paralysis.
AUTHOR INFORMATION
Accepted for publication July 31, 2000.
From the Departments of Otolaryngology, University of Michigan Medical
Center, Ann Arbor (Dr Chepeha), London Health Sciences Centre, University
of Western Ontario, London (Dr Yoo), University of Toronto, Sunnybrook and
Women's College Health Science Centre, North York, Ontario (Drs Birt, Gilbert,
and Chen).
Corresponding author: Douglas B. Chepeha, MD, University of Michigan,
Department of Otolaryngology, 1904 Taubman Center, 1500 E Medical Center Dr,
Ann Arbor, MI 48109-0312 (e-mail: dchepeha{at}umich.edu).
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