Patients with Lagophthalmos have an inability to close their eyelids. This may occur, for instance, in patients with thyroid eye disease. Symptoms include tearing and a weak eyelid.

This condition leads to a diminished blink, incomplete eyelid closure, and impairment of the nasolacrimal pumping system that produces tears and drains them away. The blink reflex and lid position are critical to maintaining the eye's surface--each blink spreads tear film over the eye and creates a continuous layer of moisture.

Patients with lagopthalmos (inability to close their eyelids) have several treatment options available to them:

SUPPORTIVE

Lubrication
Eyedrops and eye ointments are very effective in protecting the cornea, but they often result in substantially blurred vision.  Eye protection such as eye patches, eye shields, moisture chambers, and night time taping will increase eye comfort, especially when eyedrops and ointment alone are insufficient.

Mime and physiotherapy

There are only few controlled trials available on the effectiveness of physical therapy for facial palsies.  In a randomized trial on 50 patients with Bell’s palsy, mime therapy, including facial massage, relaxation exercises, muscle coordination exercises, or emotional expression exercises, resulted in improvement of facial stiffness, lip motility, and the physical appearance.

Eyelid weights
External lid weights (tape-on weights) provide an immediate, voluntary blink mechanism for treating ocular exposure associated with temporary facial paralysis such as Bell's palsy. This option is non-surgical and offers excellent comfort and ease of use.

MEDICAL THERAPY

Steroids (Cortisone) and Antivirals

Although steroids are widely used in Bell’s palsy its effectiveness in this situation has not been clearly proven. There are studies which concluded that treatment with steroids within 3 days after onset significantly improves the chance for complete recovery at 3 or 9 months, and other studies show that adding multivitamins and/or antiviral medicines also improved outcome.

SURGICAL THERAPY   

Surgical options include facial nerve decompression, eyelid lift, implantable gold weights or eyelid springs placed into the eyelid, sewing the eyelids shut (tarsorrhaphy), transposition of the temporal muscle, facial nerve grafting, and direct brow lift.  In general, surgical repair by using a combination of procedures tailored to the patients’ clinical findings works well for improving symptoms and exposure. Most patients who have had severe corneal exposure due to lagophthalmos with or without a paralytic and sagging eyelid received a combination of eyelid tightening, eyelid lift, and gold-weight implantation. Patients without severe exposure have received a single procedure or combinations of procedures.

Neurosurgery to decompress the facial nerve is controversial when performed in patients with complete Bell palsy that has not responded to medical therapy and with greater than 90% axonal degeneration, as shown on facial nerve electromyography (EMG) within 3 weeks of the onset of paralysis. The problem must be localized with magnetic resonance imaging (MRI); then, the neurosurgeon can decide which specific surgical procedure will be best for the patient.

Patients with a poor prognosis, identified by facial nerve testing or persistent paralysis, appear to benefit the most from surgical intervention.

Eyelid tightening

The eyelid, or SOOF lift, is designed to lift and suspend the midfacial musculature. The SOOF is deep to the eyelid muscle and superficial to the bone below the inferior orbital rim. Lifting the SOOF may also elevate the upper lip and the angle of the mouth to improve facial symmetry. A SOOF lift is commonly done in conjunction with a lateral tarsal strip procedure to tighten the eyelid.  A lateral tarsal strip procedure is performed to correct horizontal lower-lid laxity and to improve apposition of the lid to the globe.

Gold Weight Implants in the Eyelid

Implantable devices have been used to restore dynamic lid closure in cases of severe, symptomatic lagophthalmos. These procedures are best for patients with poor Bell phenomenon and decreased corneal sensation. Gold or platinum weights, or palpebral springs can be inserted into the eyelids. The gold-weight implantation is most commonly performed. The weight allows the upper eyelid to close with gravity when the eyelid opening muscle is relaxed. Therefore, patients must sleep with their head slightly elevated.  The implants are inert and composed of 99.99% pure gold or platinum, and are made in several sizes. They are easily removed if nerve function returns. Complications include migration of the implant, inflammation, allergic reaction, or extrusion.

Tarsorrhaphy

Tarsorrhaphy decreases horizontal lid opening by fusing the eyelid margins together to improve support of the precorneal lake of tears and to improve coverage of the eye during sleep. The procedure can be done in the office and is particularly suitable for patients who are unable or unwilling to undergo other surgery. It can be completed as either a temporary or a permanent measure. Permanent tarsorrhaphy is done if nerve recovery is not expected.  Tarsorrhaphy can be performed laterally, centrally, or medially. The lateral procedure is most common; however, it can restrict the peripheral vision. Central tarsorrhaphy offers good corneal protection, but it occludes vision and can be cosmetically unacceptable. Medial tarsorrhaphy can offer good lid closure without substantially affecting the visual field.

Direct brow lift

Brow ptosis is repaired with a direct brow lift. Care should be taken in the presence of corneal decompensation because lifting the brow can cause worsening of lagophthalmos, especially if lid closure is poor. A gold-weight implant can be placed or lower-lid resuspension can be performed simultaneously to prevent this complication.

Other procedures available from surgeons other than Dr. Siddens

Transposition of temporal muscle

Transposition of the temporalis muscle can be used to reanimate the face and to provide lid closure by using the fifth cranial nerve. Strips from the muscle and fascia are placed in the upper and lower lids as an encircling sling. Patients initiate movement by chewing or clenching their teeth.

Facial nerve grafting (hypoglossal-facial nerve anastomosis)

Reinnervation of the facial nerve by means of facial nerve grafting (hypoglossal-facial nerve anastomosis) can be used in cases of clinically significant permanent paralysis to help restore relatively normal function to the orbicularis oculi muscle or eyelids.