Paralysis of the facial nerve can cause a number of eye problems due to the inability to close the eyelids
What is a facial palsy?
The facial nerve (also known as the 7th cranial nerve) makes the muscles of the face move. There is one nerve for each side of the face. Paralysis of this nerve will cause one side of the face to stop moving. This in turn may cause the forehead to lose its creases, the eyebrow to drop, the upper eyelid to retract upwards, the eyelids to stop blinking, the eyelids to stop closing – especially at night, the lower lid to droop downwards (retraction) or roll outwards (ectropion).
Recovery from a facial palsy depends on the cause and may be complete recovery or complete palsy or any point between. In addition sometimes spasms or twitches in the face may develop as the nerve tries to reconnect during the healing process.
What eye problems do people experience due to facial palsy?
Broadly there are two categories of problems: functional and cosmetic.
Functional means that the normal functioning of the eyelids and eyebrow have been adversely affected by the palsy, whereas cosmetic means that the symmetry of the face and therefore appearance has been affected.
Inability to blink properly and to close the eyelids leads to exposure and drying out of the eye. This in turn leads to discomfort, photophobia (avoidance of bright light) and reduction in vision. Left untreated, in some people, the eye is at risk of infection and permanent loss of vision. This severe complication is rare, as usually with non-surgical or surgical intervention the eye can be made both comfortable and safe.
Right lagophthalmos (inability to close an eye)
The lower and upper eyelid can become retracted, further contributing to the difficulty in closing the eyelids.
If the eyebrow descends it can be felt as a weight on the upper eyelid. Sometimes this can reduce the upper visual field as the eyelid is pushed down by the eyebrow.
Part of the normal mechanism of tear drainage requires normal eyelid blinking. Therefore when this blinking is lost, tear drainage is reduced also. This produces watering from the eye. Therefore, paradoxically, people with a facial palsy can have an eye that is both drying out and watering.
The facial nerve (also known as the 7th cranial nerve) makes the muscles of the face move. There is one nerve for each side of the face. Paralysis of this nerve will cause one side of the face to stop moving. This in turn may cause the forehead to lose its creases, the eyebrow to drop, the upper eyelid to retract upwards, the eyelids to stop blinking, the eyelids to stop closing – especially at night, the lower lid to droop downwards (retraction) or roll outwards (ectropion).
Left lower eyelid ectropion due to facial palsy. There is also lagophthalmos
Recovery from a facial palsy depends on the cause and may be complete recovery or complete palsy or any point between. In addition sometimes spasms or twitches in the face may develop as the nerve tries to reconnect during the healing process.
What are the non surgical treatments for facial palsy?
Physiotherapy may play an important role in recovery from a facial palsy. If possible, seek out a physiotherapist who specialises in this problem.
For example in Merseyside Helen Martin at Osiris Health: http://www.osirishealth.co.uk/services/#facial-palsy
Ocular lubrication is very important to prevent the eye from drying out. The types of artificial tear-drops and ointments you use will depend on the severity of the problem and may change over time if your facial palsy improves.
Eyelid closure: The inability to close your eye at night can lead to exposure and drying out of the eye. It is possible to tape your eyelids closed using medical tape. This works well for some people, whilst others find the tape causes problems with their eyelid skin. An alternative is to use steri-strips, as bought in a pharmacy, as these are a little kinder on the skin. A further technique is to tear off a piece of Clingfilm and place it over closed eyelids. This has the effect of helping to close the lids without using the glue that is found on medical tape. Lastly gauze / cotton wool eye pads can be taped onto a closed eyelid to hold it closed. This is only of value if the eyelids stay closed underneath the pads and sometimes more than one pad is needed to achieve this. Some people combine cling film with eye pads. There is no easy solution for this problem and some experimentation may be required by an individual to discover what works for them.
Botulinum toxin injections: Botulinum toxin paralyses muscles temporarily, usually for 2-3 months. Whilst a facial palsy is itself a problem of muscle paralysis there are situations where using controlled small doses of this injection can help.
Firstly the other non-paralysed side of the face may over compensate in response to the palsy. For example, in an effort to lift the drooping eyebrow of a facial palsy, the other brow may be lifted very high by the forehead muscles. This creates a very asymmetrical appearance of the eyebrows, which can be improved by using Botox to lower the brow of the non-palsy side.
Secondly, as a facial palsy heals, unwanted spasms or twitches may occur in the facial muscles. Botox to these areas may improve both appearance and function of the face.
Lower lid taping: If the lower eyelid has become lax and rolled out it is possible to artificially tighten it using medical tape or steri-strips by pulling the lid in an outwards direction.
Left lower eyelid ectropion treated temporarily by taping
External eyelid weights are small metal weights that can be stuck to the skin of the upper eyelid in order to improve eyelid closure. This is the same principle as a surgically implanted weight (see below).
An external eyelid weight has been placed using adhesive tape to help eyelid closure
Moisture chambers are goggles that are designed to increase humidity around the eye and reduce the risk of the eye drying out. There are bespoke goggles designed specifically for people with dry eye or facial palsy, but also some people find glasses that are designed for cyclists can help. These look like a cross between swimming goggles and sunglasses.
Moisture chamber glasses have padding that reduces the effect of wind on a watery eye
What surgical treatments are there for the eye problems associated with facial palsy?
Lower lid ectropion surgery: This is surgery to correct a lower eyelid that has rolled outwards. It is usually a daycase, local anaesthetic procedure that takes approximately 45 minutes to undertake. See the webpage on ectropion surgery.
Lower lid retraction surgery: The lower eyelid may sink downwards without rolling outwards. This is known as lower eyelid retraction. To correct this surgically may involve a number of different procedures depending on your individual circumstances and include: lower eyelid tightening, lower eyelid retractor recession, medial canthal tendon tightening, hard palate graft, dermis fat graft.
Upper lid retraction surgery: The upper eyelid may retract upwards making it harder to close the eyelids. In this situation simply weakening the muscle that lifts the eyelid, and therefore dropping the upper lid downwards can be effective. This procedure is commonly performed by via an incision on the inside of the upper eyelid but sometimes through the skin.
Upper lid platinum weight surgery: By adding weight to the upper eyelid it is possible to aid eyelid closure. When we blink the muscle that lifts the upper lid relaxes to allow eyelid closure. If the upper lid has extra weight within it the lid will naturally drop further as a result. The exact weight required will be assessed in clinic using trial weights that are stuck on externally to the upper eyelid. A corresponding sterile platinum weight is then ordered to be inserted at the time of surgery.
Left - lagophthalmos (inability to close the eye); Centre - A platinum weight has been surgically implanted; Right - After weight implantation the eye can still open well
Brow lift surgery: There are a number of different techniques to surgically lift an eyebrow.
A direct brow lift involves the removal of skin just above the eyebrow. It is very effective but usually leaves a visible scar.
An indirect brow lift involves the placement of elevating buried suture(s) beneath the eyebrow at the time of upper eyelid blepharoplasty (skin removal) surgery.
A temporal brow lift involves the removal of skin at the hairline in the temple region in order to pull the brow up and lateral.
A forehead lift involves the whole or half of the forehead being undermined and pulled upwards to overcome drooping of the eyebrow area.
What will happen if I decide not to have surgery?
All of the non-surgical therapies outlined above may be used, and for many people these are sufficient to protect the eye whilst the palsy heals or for long term management if required.
What will happen before surgery?
Before the operation you will be seen in the clinic by Mr McCormick. He will ask you about the eyelid problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). He will examine your eyes. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. You will be asked to read and sign a consent form after having the opportunity to ask any questions. If you are to have a general anaesthetic, local anaesthetic with sedation or local anaesthetic alone you will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise you if you need to starve before the operation. If simple local anaesthesia is used you will not need any of these investigations and you will not need to starve prior to surgery.
What should I do about my medication?
In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin), Pradaxa (dabigatran), Xarelto (rivaroxaban), and Eliquis (apixaban). This decision is made on an individual basis and will be discussed with you before surgery. Other medication should be taken as usual unless the pre-operative team instruct you otherwise.
What are the risks and possible complications of surgery?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in these operations. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding. A collection of blood (haematoma) may be massaged and will usually settle without further surgery. A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur after eyelid surgery. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department. Whenever the skin is incised a scar may form. Every attempt is made by the surgeon to minimise and hide scars but sometimes they can be visible. The eyelid is in close proximity to the eyeball. Although extremely unlikely, whenever surgery is carried out close to the eye there is a potential risk of damage to the eye and therefore to eyesight. You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.
What should I expect after surgery?
Usually a pad will be placed on the eye, which will remain until the following day when you can remove it. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls. After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks. It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve. Usually the skin sutures used are dissolvable and will be left to fall out by themselves. There may be some mild aching at the outer corner of the eye. This settles after 6-8 weeks and is due to the suture that reattaches the lid to the bone. The time when you can return to normal activities varies from person to person. Many are happy to do so after 2 – 3 days and the vast majority after a week.
Postoperative Instructions
If an eye pad is placed it should remain until the next morning when you may remove it. For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls. Chloramphenicol ointment to the eye and wound, three times a day for 2 weeks. Follow up appointment 1 week later.
