Postoperative Lagophthalmos Research Articles

Facial Nerve Injury during External Dacryocystorhinostomy

To describe weakness of the orbicularis oculi muscle after external dacryocystorhinostomy (DCR) and propose an anatomic explanation for the complication. Retrospective, observational study. Sixteen patients (13 female, 3 male) with a mean age of 60 years (median, 61 years; range, 34-85 years). A retrospective chart review was performed of consecutive patients who had nasolacrimal duct obstruction repair by external DCR. Patients were identified who developed postoperative orbicularis oculi muscle weakness that manifested as hypometric blink or lagophthalmos with or without punctate keratopathy on the operated side. Patient parameters collected included demographic data, type of incision, incision length, use of lacrimal stent, length of follow-up, intraoperative and postoperative complications, and time to resolution of clinical findings. Statistical analysis was performed using a 2-tailed Fisher exact test with clinical significance designated at alpha = 0.05. Identification of patients with orbicularis oculi muscle weakness after external DCR, documentation of incision type, clinical findings, and recovery of function. Among 215 patients and 247 surgeries, 16 individuals (7.4%) were identified who demonstrated abnormalities of eyelid closure in the postoperative period after external DCR. Of these, 13 patients had lagophthalmos with or without hypometric blink and 3 patients had hypometric blink alone. Eleven patients underwent surgery through a nasojugal incision, 4 patients underwent surgery through a vertical incision, and 1 patient underwent surgery through an eyelid margin incision. The degree of postoperative lagophthalmos was on average 1.5 mm. Four patients developed punctate keratopathy. Follow-up ranged from 3 to 50 weeks (mean, 20 weeks). Resolution of lagophthalmos was seen on average by 14 weeks with the longest time to resolution of 32 weeks. Three individuals continued to have residual hypometric blink at the time of last follow-up. Damage to peripheral fibers of the zygomatic and buccal branches of the facial nerve as they course through the medial canthal area to innervate the upper eyelid orbicularis oculi muscle may occur during external DCR surgery. Such injury may be responsible for orbicularis oculi muscle weakness manifesting as postoperative abnormal eyelid closure and lagophthalmos. In our cohort of patients, these findings were temporary and typically resolved in several months.

Intraoperative Quantification Using Finger Force for Involutional Blepharoptosis without Postoperative Lagophthalmos

To report intraoperative quantification using finger force for involutional blepharoptosis, which helps in the prevention of postoperative lagophthalmos. We carried out levator resection on 20 involutional blepharoptic eyelids. Fissure height was examined intraoperatively to evaluate the extent of resection. If a patient presented more than 3 mm of lagophthalmos in voluntary eyelid closure but could fully open the eye, we forcibly closed the eyelid, using a finger, after voluntary eyelid closure. If more than 3 mm of lagophthalmos was still observed after forced eyelid closure, we corrected eyelid tension until lagophthalmos became less than 2 mm. Six of the ten patients (20 eyelids) presented with full eyelid opening but more than 3 mm of lagophthalmos in voluntary eyelid closure. After the upper eyelids were forcibly lowered, all six eyelids showed less than 2 mm of lagophthalmos. There were no cases of lagophthalmos 1 month postoperatively. Additional finger force makes precise quantification of blepharoptosis surgery possible and prevents postoperative lagophthalmos.

Management of Cosmetic Eyelid Surgery Complications

Purpose: Preoperative evaluation with detailed surgical planning is imperative to avoid potential complications in cosmetic eyelid surgery. Materials and Methods: Before undergoing cosmetic upper eyelid blepharoplasty, patients should be thoroughly evaluated. Patients should be examined for ptosis, dry eye syndrome, prolapsed lacrimal gland, and brow ptosis. In addition to the evaluation for dry eye syndrome, patients interested in cosmetic lower eyelid blepharoplasty should be assessed for ectropion, entropion, lid retraction, scleral show, lid laxity, and lagophthalmos. Preoperatively, risk factors for orbital hemorrhage, including hypertension, anti-platelet or anticoagulant medication, history of abnormal bruising of bleeding, or underlying diseases that may contribute to bleeding, should be assessed. Intraoperative management of cosmetic upper eyelid surgery complications should focus on decreasing the risk of postoperative ptosis, lagophthalmos, lid retraction, and lid asymmetry, with special attention to limiting the risk of visual loss secondary to orbital hemorrhage. Discussion: Management of cosmetic lower eyelid blepharoplasty complications should focus on methods to assess lower lid laxity, limit the risk of diplopia, and manage orbital hemorrhage. Results: Techniques to revise cosmetic eyelid surgery complications during the postoperative period will be described.

Correction of congenital blepharoptosis by transposition of the frontal muscle

Congential ptosis (CP) represents a significant reconstructive problem. Numerous studies have not yet provided full and satisfactory results. In this study, we have presented our experience in the surgical treatment of 108 patients by the use of Son Ye Guang's modified method--frontal muscle transposition. A total of 108 patients with CP were surgically treated at the Clinic for Plastic Surgery and Burns of the Military Medical Academy in the period 1991-2000. Unilateral ptosis was operated in 85 patients, and bilateral in 23 patients. CP was more frequently found in males (58.34%) than in females (41.66%). The youngest patient was only 5.5 years old, and the oldest was 42, the average age was 21.3 years. All patients were operated on by the same surgeon, and were monitored monthly during the first six months, and then twice a year for the next 3 years. Postoperative results were evaluated after 6 months: the action of raising the eyelids was compared to the full amplitude of movement of the eye on the healthy side. The closure of the eyelids and the symmetry of the palpebral fissure in a steady horizontal view was also assessed. The action of the opening as well as closure of the eyelids in full amplitude was obtained in all operated patients. Assymetry of the palpebral fissure in a steady horizontal view up to 1 mm did not require additional correction. In 9 cases, assymetry of the palpebral fissure greater than 1 mm was subsequently corrected. The advantages of this surgical method compared to the other, previously described techniques, were emphasized in the conclusion. The main advantage was the elimination of postoperative lagophthalmos, which represented the problem in all previously used methods.

Oculoplastic surgical techniques for protection of the eye in facial nerve paralysis.

To describe an algorithm for medical and surgical management of corneal exposure secondary to seventh cranial nerve paresis. A retrospective review of 54 patients requiring surgical intervention for seventh cranial nerve paresis was performed. Patients underwent outpatient procedures at a tertiary care facility. 31 men and 23 women, with a mean age of 55.7 years, were included in this study. They included 45 patients with involvement of the facial nerve at the time of surgery, 3 with inflammatory processes, 2 with central palsies, 1 with a traumatic paralysis, and 3 with idiopathic palsies. All 54 patients were treated both medically and surgically. Fifty-two patients underwent gold weight placement, and 39 patients underwent surgical repositioning of their lower eyelids; 24 of those patients had supplemental ear cartilage grafts inserted as well. Five patients had brow ptosis repairs, and 13 had tarsorrhaphies (9 temporary and 4 permanent). Twelve patients had confluent epithelial defects of >50% of their corneal surface, and 33 patients had smaller disruptions of their corneal epithelium. Three patients had minor complications secondary to surgical intervention. Thirty-seven patients had isolated seventh nerve palsies, and 17 patients also had fifth nerve pareses affecting their ocular surfaces. The average preoperative lagophthalmos was 6.3 mm, and the average postoperative lagophthalmos after all ocular procedures was 1.6 mm. The mean follow-up time was 19.7 months. Treatment options for seventh cranial nerve deficits are reviewed. A decision-making process for the treatment steps is proposed and analyzed.

Incidence of lagophthalmos after aponeurotic ptosis repair

This study was designed to determine the incidence of lagophthalmos following aponeurotic ptosis repair, and to establish any predictive factors for its development. Data from a prospective, interventional, non-comparative case series was reviewed. Of these 164 eyelids with acquired involutional ptosis, 134 eyelids of 75 patients had both preoperative and postoperative photographs of the eyelids in the primary and gently closed positions, and were therefore analyzed for this study. Lagophthalmos was present in 23/38 (60%) of eyelids on the first postoperative day; in 27/81 (33%) one week after surgery; and persisted in 12/134 (9%) eyelids and 8/75 (11%) patients six to twenty weeks after surgery (mean 11 weeks). The lagophthalmos of these twelve eyelids ranged from 0.5 to 1.5 mm with a mean of 0.6 mm. Both the pre-existing lower scleral show and the final height of the eyelid following surgery were significant predictors of postoperative lagophthalmos. Neither eyelid excursion nor the degree of change in eyelid height from pre- to post-surgery was significantly associated with eyelid closure.

Effectiveness of homologous cadaveric fascia lata and role of suture fixation to tarsus in frontalis suspension.

The results of frontalis suspension (double rhomboid technique with preserved homologous cadaver fascia) were compared in two surgical groups: 1) patients in whom the fascia was sutured to the tarsus and 2) patients in whom the fascia was not sutured to the tarsus. The study was performed to determine the optimum surgical technique and to determine whether preserved cadaver fascia is a suitable suspensory material. All data retrospectively reviewed included 1) predisposing cause of severe blepharoptosis, 2) results in the two groups of patients, suture fixation and nonsuture fixation, and 3) surgical complications. Of the 27 patients (36 eyelids), the fascia was sutured to the tarsus in 15 patients (20 eyelids) and not sutured to the tarsus in 12 patients (16 eyelids). In the suture fixation group, no undercorrections occurred, but four of 20 eyelids had lower than expected eyelid creases and six had residual dermatochalasis. Six patients had lagophthalmos with corneal exposure that required intense corneal lubrication, and three such patients required temporary tarsorrhaphy for 3 weeks. In the group without suture fixation, two patients had undercorrection (one with ocular cicatricial pemphigoid and the other with myotonic dystrophy). The mean followup period was 44 months. We conclude that preserved fascia provides excellent results with or without fixation of the fascia to the tarsus. In patients with suture fixation, the eyelid crease may form just above the point at which the fascia is sutured to tarsus and result in a low eyelid crease. Excision of excess skin should be considered at the time of frontalis suspension in selected patients in whom the fascia is fixated to the tarsus or who have preexisting dermatochalasis. Patients with suture fixation may have significant temporary postoperative lagophthalmos.