The Eye Specialist
Professor S A Sadiq DO, MRCOphth, FRCS, FRCOphth, DM
Consultant Ophthalmic Surgeon, North West UK
A nerve called the facial nerve controls muscles of the face and eyelids. These muscles lift the eyebrow and help close the eyelids, protecting the front of the eye. With a facial palsy, the facial nerve for some reason stops working. Consequently, there is reduced or absent movement of these muscles. The facial nerve supplies a circle of muscle around the eyelids which closes the eyelids over the front of the eye to protect it and to keep it lubricated with the natural tears. In facial nerve palsy, the eyelids are unable to close or are only able to partially close (lagophthalmos).
I am able to treat these symptoms and offer a variety of options to patients depending on the level of facial palsy.
In facial palsy, the eyebrow may droop, the upper lid may be too high (retracted) due to un-opposed action of the muscle which opens the upper eyelid (levator muscle), and the lower lid may be droopy and sag downwards (exacerbated by the effect of gravity). The eyelids do not close over the eye which can make it susceptible to discomfort and visual loss. The aims of treatment are to improve the comfort of the eye and preserve vision. The secondary aims are to improve the cosmesis and reduce symptoms such as watering.
This is often done as a static and fixed lift of the eyebrow in the area of drooping. This may be done by an incision above the eyebrow where tissue is removed and the eyebrow sutured to the deep tissue of the forehead (periosteum). Other methods involve the placement of deep stitches that lift the eyebrow – these are done with smaller incision through the hairline.
The risks of this operation include numbness of the head, scarring above the eyebrow or in the forehead and the exposure of any deep stitches. The eyebrow may fall again over time due to the continuing effects of gravity.
The aim of this is to make the upper lid lower so that it covers more of the cornea and allows better closure of the eye. This is done by weakening the muscle that opens the eye (levator muscle recession) or by inserting a weight into the upper eyelid to help the eyelid close with gravity. The former is usually done through the back of the eyelid and can be done under local anaesthetic, and repeated if a further drop of the upper eyelid height is required. A gold weight or platinum chain is usually placed through an incision in the front of the eyelid.
The risks of levator recession are that it can be difficult to control the contour and position of the upper lid. If the lid remains high, a repeat procedure is required, and if the eyelid is too low, then a reversal operation may be required. A weight may be too heavy and be seen as a bulky mass through the skin of the upper eyelid. Sometimes a large weight can extrude through the skin. A heavy weight can also make the vision blurry by causing astigmatism.
The aims of this are to lift the lower eyelid and improve its position, reduce watering and increase the closure of the eye. Medial canthoplasty is performed in the corner by hitching the inner part of the lower eyelid to the inner part of the upper eyelid with stitches, This can be done under local anaesthetic and is a short procedure. The same can be done at the outer part of the eye using stitches to the covering of the outer wall of the bone (lateral canthal strip or lateral canthopexy). The central part of the eyelid is difficult to lift and may require a larger operation called a scaffold procedure where tissue is inserted into the middle of the eyelid (often from the nose or ear). This physically lifts up the lower eyelid. It may require a skin graft over the front in order to lift the eyelid further.
The main risks with lower eyelid surgery are that the lower lid may droop or sag again in the future due to the effects of gravity. There are scars associated with the surgery and it can be very difficult to reduce watering with any kind of lower eyelid operation.