Brow Ptosis After Temporal Artery Biopsy

Abstract

Brow Ptosis after Temporal Artery Biopsy Incidence and Associations Ann P. Murchison, MD, MPH, 1 Jurij R. Bilyk, MD 2 Objective: Temporal artery biopsy (TAB), performed for the diagnosis of giant cell arteritis, has a low reported rate of complications. One complication is damage to the facial nerve branches, which can result in brow ptosis and/or orbicularis oculi weakness. However, the incidence of facial nerve damage after TAB is unknown. Design: Prospective, institutional review board–approved study of all TABs performed by 2 surgeons over a 17-month period. Participants: Seventy patients undergoing 77 TABs. Methods: Demographic data, including age, gender, and race/ethnicity, were collected for all patients. Frontalis and orbicularis oculi muscle function were evaluated pre- and postoperatively in all patients. The use of blood thinners, location of the incision, length of incision and biopsy, biopsy results, and procedure difficulty were recorded. Incidence of postoperative facial nerve damage, other complications, and rates of facial nerve recovery were evaluated. Analysis of variables was performed for any potential correlation with facial nerve damage. Main Outcome Measures: Incidence of facial nerve damage. Results: Analysis included 75 biopsies performed in 68 patients. The majority of the patients were white (75.0%) and female (67.6%). The mean age was 72.6 years (range, 51–96). Postoperative facial nerve damage was found in 12 patients (16.0%) and 58.3% of these fully resolved at an average of 4.43 months (range, 1– 6). Two patients (2.7%) had postoperative infections. There was no correlation with facial nerve damage and use of blood thinners, biopsy result, surgeon, procedure difficulty, incision length, or specimen length. The distance from the incision to both the orbital rim and the brow was significant: Incisions farther from the orbital rim and brow were less likely to have postoperative facial nerve damage. Conclusions: There is a 16.0% incidence of postoperative facial nerve damage with TABs, which recovers fully in over half of patients. Incisions closer to the orbital rim and brow were more likely to have postoperative facial nerve dysfunction. Incisions ⬎35 mm from both the orbital rim and brow or above the brow were less likely to have postoperative brow ptosis. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. Ophthalmology 2012;119:2637–2642 © 2012 by the American Academy of Ophthalmology. Temporal artery biopsy (TAB) is used in the diagnosis of giant cell arteritis (GCA), a systemic vasculitis with potential for severe, permanent vision loss. For this di- agnosis, TAB is considered the gold standard and, gen- erally, a low-risk procedure. The majority of reported complications are relatively minor, such as hematoma formation, scarring, infection, and wound dehiscence. 1⫺4 The most concerning report of a complication is that of a cerebrovascular accident after biopsy, but given the ubiq- uity of TAB, this seems to be an extremely rare event. 4 There are few reports of facial nerve injury with biopsy, despite the anatomic proximity of the frontal branch of the facial nerve to the superficial temporal artery (STA). 5⫺8 There are no data on the incidence of facial nerve injury after TAB or factors that correlate with this complication. Materials and Methods A prospective study of all TABs performed by 2 surgeons over 17 months was conducted after institutional review board ap- proval. All patients were referred by a neuroophthalmologist for © 2012 by the American Academy of Ophthalmology Published by Elsevier Inc. histologic examination of possible GCA. All surgery was car- ried out in a standard fashion, as described, with the addition of measurements of the location of the incision, length of the incision and biopsy, and difficulty of the procedure. Demo- graphic data were collected, including patient age, gender, self-reported race/ethnicity, and use of blood thinners. No pa- tient had anticoagulant or antiplatelet medication(s) stopped or altered before the procedure. Side of the biopsy, result of biopsy, and surgeon performing procedure were also noted. The position of the brows as well as frontalis and orbicularis oculi muscle function were measured and recorded in the preopera- tive holding area. All procedures were performed using local anesthetic infil- tration containing epinephrine with intravenous sedation in an ambulatory surgical setting. A “safety line” was drawn connect- ing the tragus to a point 2.0 cm from the most lateral brow cilia. 9,10 The distance from this “safety line” to the lateral orbital rim at the level of the lateral canthus was recorded. The location of this line did not influence the incision site. The course of the STA was mapped out with Doppler ultrasonog- raphy in all cases, and the area of strongest Doppler signal was marked with a pen. A skin incision was made directly over the premarked STA course with a #15 Bard Parker blade and dissection through the dermis was carried out with blunt-tipped ISSN 0161-6420/12/$–see front matter http://dx.doi.org/10.1016/j.ophtha.2012.07.020