Outcomes of lower eyelid retractor recession and lateral horn lysis in lower eyelid elevation for facial nerve palsy

Abstract

PurposeTo report outcomes and complications of lower eyelid retractor recession and lateral horn lysis (RR) for lower eyelid elevation in patients with facial nerve palsy (FNP).Patients and methodsRetrospective review. Patients with FNP undergoing RR alone (group 1) or with adjunctive procedures (canthal suspension-group 2, tarsorrhaphy-group 3, and full-thickness skin graft-group 4) during a 5-year period were included. Patient demographics, lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records. Measures of lower eyelid height (LEH) and lid lag on downgaze were obtained from standard photographs.ResultsForty-two patients (23 females, mean age was 59 years) were included. Mean follow-up was 24 months (range 6-77). Median improvement in LEH following surgery was significant in Group 1 (0.90 mm, IQR: 0.37-0.91, P=0.20) and in Group 2 (0.51 mm, IQR: 0.30-1.37, P<0.001), respectively. Median improvement in blink lagophthalmos was 3.00 mm (IQR: 3.00-3.50, P=0.02) in Group 1 and 3.50 mm (IQR: 1.75-5.00, P<0.001) in Group 2. Median improvement in lagophthalmos on gentle eye closure was 2.00 mm (IQR: 1.50-3.00, P=0.02) in Group 1 and 1.00 mm (IQR: 0-2.13, P=0.006) in Group 2. No new cases of ectropion were noted. 23.5% of patients required a repeat RR at a mean interval of 20 (range 1-70) months and a further 9.8% required a third procedure at a mean interval of 21 (range 18-29) months.ConclusionRR improves lower eyelid retraction and lagophthalmos in FNP either alone or when combined as an adjunctive procedure. It does not aggravate paralytic ectropion although repeated retractor recessions may be required to improve retraction.

Figure 1

Example of measurement of lower eyelid height from standard photographs with Adobe Photoshop tool. The distance from the central pupil reflex to the central lower eyelid margin is measured and divided by the horizontal corneal diameter, which is taken to be the white-to-white distance on standard photographs. This ratio was then multiplied by a constant (K=11.68) to give the central pupil to lower eyelid distance. A full colour version of this figure is available at the Eye journal online.

Figure 2

Lower eyelid ectropion. (a) Left lower eyelid ectropion pre-operatively. (b) post-operatively three months after retractor recession and canthal suspension procedure (c) recurrence of lower eyelid ectropion six months after first surgery (d) patient underwent a second procedure of retractor recession and full-thickness skin graft with improvement of ectropion post-operatively. (e) Another patient with left facial nerve palsy without lower eyelid malposition (f) Left lower eyelid cellulitis after retractor recession and canthal suspension surgery (g) Resolution of cellulitis with intravenous antibiotics. (h) Residual left punctal ectropion 8 months after surgery.

Figure 3

Changes in lower eyelid contour and lateral flare before and after surgery. (a) Left lower eyelid lateral flare pre-operatively (b) post-operatively. (c) Right lower eyelid lateral flare pre-operatively (d) post-operatively. A full colour version of this figure is available at the Eye journal online.

Figure 4

Lid lag on downgaze. (a) No lid lag on left eye pre-operatively. (b) Lid lag present on left eye post-operatively. (c) No lid lag on left eye pre-operatively. (d) Lid lag present on left eye post-operatively. A full colour version of this figure is available at the Eye journal online.