|Year : 1963 | Volume
| Issue : 2 | Page : 30-33
Paralytic lagophthalmos and its treatment
Kailash Nath, BR Shukla
M. U. Institute of Ophthalmology, Aligarh, India
|Date of Web Publication||28-Jan-2008|
M. U. Institute of Ophthalmology, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nath K, Shukla B R. Paralytic lagophthalmos and its treatment. Indian J Ophthalmol 1963;11:30-3
Approximately one in every one thousand patients visiting this hospital, suffer from infranuclear type of facial palsy leading to paresis or paralysis of Orbicularis Oculi. The involvement of the nerve occurs following mastoiditis, in mastoid operations, or following trauma or exposure as in Bell's Palsy. The cases following exposure recover while those following mastoiditis or trauma suffer from a more permanent damage leading to an immobile hanging upper lid, a drooping lower lid with accompanying ectropion of the lower punctum with persistent watering of the eye and exposure keratitis. Aesthetically, his appearance is not pleasant when he attempts to close the lids.
So far, the common mode of treatment has been tarsorrhaphy of the outer canthus after Elschning or McLaughlin (1960). In more severe cases tarsorrhaphy of both the canthi has been performed. This surgery was supplemented with local lubricants, antibiotics and a liberal regimen of vitamins. Tarsorrhaphy and local medicaments succeeded in checking the, exposure keratitis temporarily but functionally gave poor results. Further, the appearance of the patient with both the lids of one eye fully or partly stitched, is neither convenient nor desirable. Moreover, the keratitis recurs as soon as the two lids are separated and spring back to their original positions, Thus, one has to perform repeated tarsorraphies and one encounters a series of disappointments every time the lids are opened. The permanent double tarasorrhaphy as stated above is not desirable.
With the object of giving better functional and cosmetic results, Glazenov (1955) advocated the introduction of fascia lata graft in the lower lid. Fascia lata graft helps to support the lower lid against the eye ball and it also decreases the epiphora but the procedure does not impart any movement to the upper lid and fails to check the exposure keratitis to any significant extent.
Ambos (1957) attempted to overcome the unrestricted tonus of the levator by making the upper lid heavier. He successfully introduced a subcutaneous implant of a small V2A - steel plate into the upper lid. Four months after introduction, one case showed the development of pseudoepethelium around the plate. There was no irritation in the surrounding tissues. In this procedure, lower lid and punctum remain unattended. However, Ambos has suggested the use of magnetic implants in both lids. Illing (1958) described a similar procedure but he prefers to use gold instead of V2A - steel plate and also covers his gold plates with a non-irritating material. In both the procedures of Ambos and Illing, the lower lid remains untreated and the ectropion of lower lid and punctum with epiphora is bound to persist. Further, any free movement of the upper lid is out of question. Probably, a combination of fasica lata graft with Illing's or Ambos' method would give better results.
Schrick (1957) came out with a new proposition which consisted of raetocain injection in the levator muscle belly. This causes transitory paresis of levator which lasts for several weeks. Those cases which were selected were severely injured and uncooperative patients. Permanent results were neither claimed nor present. The lower lid drooped and its function was impaired.
Ibrahim (1959) believed in making the lids taut by passing a tantallum wire from the lateral palpebral ligament into a bony hole drilled in the outer bony canthus. This procedure, although it supports both the lid against the eyeball, does not impart any movement, but lagophthalmos, ectropion of the lower lid and lower punctum are corrected. But for the absence of movement of the upper lid and variable residual lagophthalmos, the procedure appears to be the best amongst all the procedures stated above.
Pakhnova (1960) has described a technique of partial myotomy of the levator, thus weakening the action. The principle is the same as that of some earlier techniques of weakening the levator or that of counter-acting its tonus by increasing the weight of the upper lid.
| Case Reports|| |
Temporalis transplant as described by (Mlle; and Millard (1957) was performed in three cases. All cases were of more than one year's duration. Cases 1 & 2 showed marked improvement in lid closure, keratitis and epiphora See [Figure - 1],[Figure - 2],[Figure - 3],[Figure - 4]. In the third case, there was not much change in lid closure, but epiphora and keratitis disappeared [Figure - 5],[Figure - 6]. These cases were followed tip for more than a year.
| Technique of Temforalis Transplant|| |
The head is shaved. After tarsorrhaphy, a 2" hairline incision is made on both the lids on the side to be operated upon. The incision is extended upto the zygomatic arch. Temporalis fascia and muscle are exposed. The anterior portion of the temporalis muscle is mobilised from its origin along with its fasica and is brought anteriorly. A hole is drilled in the zygoma at the level of external canthal ligament enough to accommodate freely the temporalis fascia for both the lids. It is divided into two portions one for the upper lid and the other for the lower lid. The two portions are passed through the hole in the zygoma and brought forward. To end the operation, a vertical incision of about 2.5 cm. is made at about 2 mm. from medial canthus; fascia lata needle is passed both above and below, under the orbicularis and the two prepared ends of temporalis fascia are brought forward and taken out of this new incision. The two ends are stitched with supramid carefully across the medial palpebral ligaments to the periosteum. The incisions are subcutaneously closed in two layers. A drainage tube is left in the temporal incision for 48 hours. Post-operatively, the patient is kept on antibiotics for a week. After a week stitches are removed; the tarsorrhaphy is opened after three weeks when the patient can be discharged.
| Comments|| |
A large number of techniques have been advocated from time to time for the treatment of lagophthalmos due to infra-nuclear type of facial paralysis and so far none has proved to be ideal. The criteria for a good technique are
(i) It should support the lower lid against the globe.
(ii) It should prevent ectropion of lower punctum and thus should keep the epiphora in check.
(iii) It should permit movement of the upper lid so that exposure keratitis and lagophthalmos do not recur.
(iv) Cosmetic appearance should be good.
To achieve the above aims, nerve transplant and nerve anastomoses appear to be ideal. These procedures give good results when the cases are undertaken during the first year of their occurrence. If more time passes between the occurrence of the lesion and the performance of surgery, the muscle fibres atrophy and reaction of degeneration manifeats itself. Upto some extent the atrophy of the muscle can be kept in check by local massage, splints and application of galvanic currents to the muscle, the value of which is however, questionable.
| Conclusion|| |
Temporalis Transplant (Gilles-1957) is an ideal technique for the treatment of cases suffering from Lagophthalmos due to infra-nuclear type of facial palsy of more than one year's duration. It looks after both the lids, checks epiphora, prevents exposure keratitis and permits a certain amount of movement to the lids. Cosmetically, the appearance is good.
| Summary|| |
Various techniques for the treatment of Lagophthalmos due to infra-nuclear type of facial palsy are given. Their advantages and disadvantages are discussed. Three cases done by the authors are cited. It is concluded that in facial palsy of more than one year's duration, Temporalis transplant offers best results.
| References|| |
Ambos, E., (1457) -Wien, Klien. Wsches. ; 69, p. 866, Nov. 8.
Gilles H. & Millard, J. R., (1957)-The Principles and Art of Plastic Surgery Vol. II, Butterworth, London, p. 6o8.
Glalzenov, S. Y., (1955)-Vestn. Optal. ; 34, p. 25-27, July-Aug.
Goldstien (1934)-Arch, Oph. ; 11, p. 389.
Ibrahim, H. A., (1959), Bull. Oph. Soc. Egypt, 52, p. 299-3oo.
Illing, K. 31., (1958), Klin. Augenheilk; 132, p. 410-411.
McLaughlin, C. R -
(1960), Br. J. of Plastic Surg.; 2, p. 87.
Pakhnova, A. I., (196o), Oph. Lit. 14, p. 1205.
Schnek, H. (1957), Ophthal, Ges., 3rd. Ann. Meeting, May-June, p. 178-181.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]