Management of the Eye in the Setting of Facial Nerve Paralysis

  • Richard C. Allen


Due to incomplete eyelid closure, the eye is acutely at risk in a patient with facial paralysis. Involvement of an ophthalmologist is necessary to appropriately examine the patient, safeguard the eye, and plan subsequent periocular rehabilitation. Early treatment involves lubrication and possibly the placement of a tarsorrhaphy. Rehabilitation may involve improving the position of the eyebrow, upper eyelid, lower eyelid, or midface. Epiphora has a multitude of potential causes in the patient with a facial paralysis including reflex tearing, eyelid malposition, and a defective lacrimal pump. Patients with a coexisting trigeminal nerve palsy or neurotrophic cornea are at a heightened risk of ocular morbidity and must be treated as so. The purpose of this chapter is to review the evaluation and management of the ocular concerns in a patient with facial nerve paralysis.


Lagophthalmos Exposure keratopathy Brow ptosis Eyelid retraction Paralytic ectropion Scleral lens Synkinesis Tarsorrhaphy Epiphora 


  1. 1.
    Bhama P, Bhrany AD. Ocular protection in facial paralysis. Curr Opin Otolaryngol Head Neck Surg. 2013;21:353–7.CrossRefGoogle Scholar
  2. 2.
    Lee V, Currie Z, Collin JRO. Ophthalmic management of facial nerve palsy. Eye (Lond). 2004;18:1225–34.CrossRefGoogle Scholar
  3. 3.
    Henstrom DK, Lindsay RW, Cheney ML, Hadlock TA. Surgical treatment of the periocular complex and improvement of quality of life in patients with facial paralysis. Arch Facial Plast Surg. 2011;13:125–8.PubMedGoogle Scholar
  4. 4.
    Ziahosseini K, Venables V, Neville C, Nduka C, Patel B, Malhotra R. Occurrence and severity of upper eyelid skin contracture in facial nerve palsy. Eye. 2016;30:713–7.CrossRefGoogle Scholar
  5. 5.
    Malhotra R, Ziahosseini K, Litwin A, Nduka C, El-Shammah N. CADS grading scale: toward better grading of ophthalmic involvement in facial nerve paralysis. Br J Ophthalmol. 2016;100:866–70.CrossRefGoogle Scholar
  6. 6.
    Ziahosseini K, Nduka C, Malhotra R. Ophthalmic grading of facial paralysis: need for a closer look. Br J Ophthalmol. 2015;99:1171–5.CrossRefGoogle Scholar
  7. 7.
    Lipham WJ, Tawfik HA, Dutton JJ. A histologic analysis and three-dimensional reconstruction of the muscle of Riolan. Ophthal Plast Reconstr Surg. 2002;18:93–8.CrossRefGoogle Scholar
  8. 8.
    Takahashi Y, Dadizaki H. Meibomian gland dysfunction and cranial nerve VII palsy. Ophthal Plast Reconstr Surg. 2015;31:179–81.CrossRefGoogle Scholar
  9. 9.
    Call CB, Wise RJ, Hansen MR, Carter KD, Allen RC. In vivo examination of Meibomian gland morphology in patients with facial nerve palsy using infrared meibography. Ophthal Plast Reconstr Surg. 2012;28:396–400.CrossRefGoogle Scholar
  10. 10.
    Shah CT, Blount AL, Nguyen EV, Hassan AS. Cranial nerve seven palsy and its influence on Meibomian gland function. Ophthal Plast Reconstr Surg. 2012;28:166–8.CrossRefGoogle Scholar
  11. 11.
    Marcet MM, Shtein RM, Bradley EA, et al. Safety and efficacy of lacrimal drainage system plugs for dry eye syndrome: a report by the American Academy of Ophthalmology. Ophthalmology. 2015;122:1681–7.CrossRefGoogle Scholar
  12. 12.
    Seiff SR. Surgical management of seventh nerve paralysis and floppy eyelid syndrome. Curr Opin Ophthalmol. 1999;10:242–6.CrossRefGoogle Scholar
  13. 13.
    Diamond JP. Temporary tarsorrhaphy with cyanoacrylate adhesive for seventh-nerve palsy. Lancet. 1990;335:1039.CrossRefGoogle Scholar
  14. 14.
    Ellis MF, Daniell M. An evaluation of the safety and efficacy of botulinum toxin type A (BOTOX) when used to produce a protective ptosis. Clin Experiment Ophthalmol. 2001;29:394–9.CrossRefGoogle Scholar
  15. 15.
    Naik MN, Gangopadhyay N, Fernandes M, Murthy R, Honavar SG. Anterior chemodenervation of levator palpebrae superioris with botulinum toxin type-A (Botox) to induce temporary ptosis for corneal protection. Eye (Lond). 2008;22:1132–6.CrossRefGoogle Scholar
  16. 16.
    Tanenbaum M, Gossman MD, Bergin DJ, Friedman HI, Lett D, Haines P, McCord CD Jr. The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure. Ophthalmic Surg. 1992;23:418–25.PubMedGoogle Scholar
  17. 17.
    Tao JP, Vemuri S, Patel AD, Compton C, Nunery WR. Lateral tarsoconjunctival onlay flap lower eyelid suspension in facial nerve paresis. Ophthal Plast Reconstr Surg. 2014;30:342–5.CrossRefGoogle Scholar
  18. 18.
    Weyns M, Koppen C, Tassignon MJ. Scleral contact lenses as an alternative to tarsorrhaphy for the long-term management of combined exposure and neurotrophic keratopathy. Cornea. 2013;32:359–61.CrossRefGoogle Scholar
  19. 19.
    Gire A, Kwok A, Marx DP. PROSE treatment for lagophthalmos and exposure keratopathy. Ophthal Plast Reconstr Surg. 2013;29:e38–40.CrossRefGoogle Scholar
  20. 20.
    Abell KM, Baker RS, Cowen DE, Porter JD. Efficacy of gold weight implants in facial nerve palsy: quantitative alterations in blinking. Vision Res. 1998;38:3019–23.CrossRefGoogle Scholar
  21. 21.
    Bair RL, Harris GJ, Lyon DB, Komorowski RA. Noninfectious inflammatory response to gold weight eyelid implants. Ophthal Plast Reconstr Surg. 1995;11:209–14.CrossRefGoogle Scholar
  22. 22.
    Fowler J Jr, Tahlor J, Storrs F, et al. Gold allergy in North America. Am J Contact Dermat. 2001;12:3–5.PubMedGoogle Scholar
  23. 23.
    Silver AL, Lindsay RW, Cheney ML, Hadlock TA. Thin-profile platinum eyelid weighting: a superior option in the paralyzed eye. Plast Reconstr Surg. 2009;123:1697–703.CrossRefGoogle Scholar
  24. 24.
    Berghaus A, Neumann K, Schrom T. The platinum chain: a new upper-lid implant for facial palsy. Arch Facial Plast Surg. 2003;5:166–70.CrossRefGoogle Scholar
  25. 25.
    Bladen JC, Norris JH, Malhotra R. Cosmetic comparison of gold weight and platinum chain insertion in primary upper eyelid loading for lagophthalmos. Ophthal Plast Reconstr Surg. 2012;28:171–5.CrossRefGoogle Scholar
  26. 26.
    Mancini R, Taban M, Lowinger A, Nakra T, Tsirbas A, Douglas RS, et al. Use of hyaluronic acid gel in the management of paralytic lagophthalmos: the hyaluronic acid gel ‘gold weight’. Ophthal Plast Reconstr Surg. 2009;25:23–6.CrossRefGoogle Scholar
  27. 27.
    Singh M, Kruse C, Eriksson E, Caterson EJ. Deep temporal fascia coverage of the loading weight in paralytic lagophthalmos patients. J Craniofac Surg. 2015;26:1631–3.CrossRefGoogle Scholar
  28. 28.
    Foster JA, Perry JD, Cahill KV, Holck DE, Dugler L. Processed human pericardium barrier for gold weight implantation. Ophthal Plast Reconstr Surg. 2004;20:107–9.CrossRefGoogle Scholar
  29. 29.
    Mavrikakis I, Beckingsale P, Lee E, Riaz Y, Brittain P. Changes in corneal topography with upper eyelid gold weight implants. Ophthal Plast Reconstr Surg. 2006;22:331–4.CrossRefGoogle Scholar
  30. 30.
    Rozen S, Lehrman C. Upper eyelid postseptal weight placement for the treatment of paralytic lagophthalmos. Plast Reconstr Surg. 2013;131:1253–65.CrossRefGoogle Scholar
  31. 31.
    Saleh GM, Mavrikakis I, de Sousa JL, Xing W, Malhotra R. Corneal astigmatism with upper eyelid gold weight implantation using the combined high pretarsal and levator fixation technique. Ophthal Plast Reconstr Surg. 2007;23:381–3.CrossRefGoogle Scholar
  32. 32.
    Demirci H, Frueh BR. Palpebral spring in the management of lagophthalmos and exposure keratopathy secondary to facial nerve palsy. Ophthal Plast Reconstr Surg. 2009;25:270–5.CrossRefGoogle Scholar
  33. 33.
    Levine RE, Shapiro JP. Reanimation of the paralyzed eyelid with the enhanced palpebral spring or gold weight: modern replacements for tarsorrhaphy. Facial Plast Surg. 2001;16:325–36.CrossRefGoogle Scholar
  34. 34.
    Arion HG. Dynamic closure of the lids in paralysis of the orbicularis muscle. Int Surg. 1972;57:48–50.PubMedGoogle Scholar
  35. 35.
    Hasmat S, Lovell NH, Eviston T, Ekmejian R, Suaning GJ, Clark J. Creating eye closure in patient with facial nerve paralysis using an implantable solenoid actuator. Conf Proc IEEE Eng Med Biol Soc. 2015;2015:1357–60.PubMedGoogle Scholar
  36. 36.
    Barmettler A, Nissanka N, Rosenblatt MI, Rao R, Lipson D, Lelli GJ Jr. Magnetic systems for tarsorrhaphy. Ophthal Plast Reconstr Surg. 2014;30:305–8.CrossRefGoogle Scholar
  37. 37.
    Hinzpeter EN, Riehm E. Preliminary experience with lid magnets for paralytic lagophthalmos. Trans Ophthalmol Soc UK. 1976;96:73–8.PubMedGoogle Scholar
  38. 38.
    Seiff SR, Boerner M, Carter SR. Treatment of facial palsies with external eyelid weights. Am J Ophthalmol. 1995;120:652–7.CrossRefGoogle Scholar
  39. 39.
    Demirci H, Hassan AS, Reck SD, Frueh BR, Elner VM. Graded full-thickness anterior blepharotomy for correction of upper eyelid retraction not associated with thyroid eye disease. Ophthal Plast Reconstr Surg. 2007;23:39–45.CrossRefGoogle Scholar
  40. 40.
    Hassan AS, Frueh BR, Elner VM. Mullerectomy for upper eyelid retraction and lagophthalmos due to facial nerve palsy. Arch Ophthalmol. 2005;123:1221–5.CrossRefGoogle Scholar
  41. 41.
    Compton CJ, Clark JD, Nunery WR, Lee HB. Recession and extirpation of the lower eyelid retractors for paralytic lagophthalmos. Ophthal Plast Reconstr Surg. 2015;31(4):323.CrossRefGoogle Scholar
  42. 42.
    Sira M, Norris JH, Nduka C, Malhotra R. Transcaruncular medial canthal tendon plication with lower eyelid suture sling in facial nerve palsy. Orbit. 2014;33:159–63.CrossRefGoogle Scholar
  43. 43.
    Dailey RA, Marx DP, Ahn ES. Porcine dermal collagen in lower eyelid retraction repair. Ophthal Plast Reconstr Surg. 2015;31:233–41.CrossRefGoogle Scholar
  44. 44.
    Graziani C, Panico C, Botti G, Collin RJ. Subperiosteal midface lift: its role in static lower eyelid reconstruction after chronic facial nerve palsy. Orbit. 2011;30:140–4.CrossRefGoogle Scholar
  45. 45.
    Olver JM. Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy. Br J Ophthalmol. 2000;84:1401–6.CrossRefGoogle Scholar
  46. 46.
    Madge SN, Malhotra R, Desousa J, et al. The lacrimal bypass tube for lacrimal pump failure attributable to facial palsy. Am J Opthalmol. 2010;149:155–9.CrossRefGoogle Scholar
  47. 47.
    Lim C, Martin P, Benger R, Kourt G, Ghabrial R. Lacrimal canalicular bypass surgery with the Lester Jones tube. Am J Ophthalmol. 2004;137:101–8.CrossRefGoogle Scholar
  48. 48.
    Scott G, Balsiger H, Kluckman M, Fan J, Gest T. Patterns of innervation of the lacrimal gland with clinical application. Clin Anat. 2014;27:1174–7.CrossRefGoogle Scholar
  49. 49.
    Falzon K, Galea M, Cunniffe G, Logan P. Transconjunctival botulinum toxin offers an effective, safe and repeatable method to treat gustatory lacrimation. Br J Ophthalmol. 2010;94:379–80.CrossRefGoogle Scholar
  50. 50.
    Montoya FJ, Riddell CE, Caesar R, Hague S. Treatment of gustatory hyperlacrimation (crocodile tears) with injection of botulinum toxin into the lacrimal gland. Eye (Lond). 2002;16:705–9.CrossRefGoogle Scholar
  51. 51.
    Razfar A, Branstetter BF, Christopoulos A, et al. Ocular outcomes after gold weight placement and facial nerve resection. Otolaryngol Head Neck Surg. 2009;140:82.CrossRefGoogle Scholar
  52. 52.
    Watts TL, Chard R, Weber SM, Wax MK. Immediate eye rehabilitation at the time of facial nerve sacrifice. Otolaryngol Head Neck Surg. 2011;144:353.CrossRefGoogle Scholar
  53. 53.
    Maas CS, Benecke JE, Holds JB, Schoenrock LD, Simo F. Primary surgical management for rehabilitation of the paralyzed eye. Otolaryngol Head Neck Surg. 1994;110:288–95.CrossRefGoogle Scholar
  54. 54.
    Chen C, Malhotra R, Muecke J, Davis G, Selva D. Aberrant facial nerve regeneration (AFR): an under-recognized cause of ptosis. Eye (Lond). 2004;18:159–62.CrossRefGoogle Scholar
  55. 55.
    Couch SM, Chundury RV, Holds JB. Subjective and objective outcome measures in the treatment of facial nerve synkinesis with onabotulinumtoxinA (Botox). Ophthal Plast Reconstr Surg. 2014;30:246–50.CrossRefGoogle Scholar
  56. 56.
    Cecini M, Pavese C, Comelli M, et al. Quantitative measurement of evolution of postparetic ocular synkinesis treated with botulinum toxin type A. Plast Reconstr Surg. 2013;132:1255–64.CrossRefGoogle Scholar
  57. 57.
    Chua CN, Quhill F, Jones E, Voon LW, Ahad M, Rowson N. Treatment of aberrant facial nerve regeneration with botulinum toxin A. Orbit. 2004;23:213–8.CrossRefGoogle Scholar
  58. 58.
    Patil-Chhablani P, Murthy S, Swaminathan M. Ophthalmic profile and systemic features of pediatric facial nerve palsy. Eye Sci. 2015;30:147–50.PubMedGoogle Scholar
  59. 59.
    Alsuhaibani AH, Bosley TM, Goldberg RA, Al-Faky YH. Entropion in children with isolated peripheral facial nerve paresis. Eye (Lond). 2012;26:1095–8.CrossRefGoogle Scholar
  60. 60.
    Pasco NY, Kikkawa DO, Korn BS, Punja KG, Jones MC. Facial nerve paralysis: an unrecognized cause of lower eyelid entropion in the pediatric population. Ophthal Plast Reconstr Surg. 2007;23:126–9.CrossRefGoogle Scholar
  61. 61.
    Terzis JK, Karypidis D. Blink restoration in adult facial paralysis. Plast Reconstr Surg. 2010;126:126–39.CrossRefGoogle Scholar
  62. 62.
    Terzis JK, Karypidis D. The outcomes of dynamic procedures for blink restoration in pediatric facial paralysis. Plast Reconstr Surg. 2010;125:629–44.CrossRefGoogle Scholar
  63. 63.
    Sadiq SA, Kharmasena A. Dynamic muscle transfer in facial nerve palsy: the use of contralateral orbicularis oculi muscle. Facial Plast Surg. 2015;31:145–51.CrossRefGoogle Scholar
  64. 64.
    Frigerio A, heaton JT, Cavallari P, Knox C, Hohman MH, Hadlock TA. Electrical stimulation of eye blink in individuals with acute facial palsy: progress toward a bionic blink. Plast Recontr Surg. 2015;136:515e–23e.CrossRefGoogle Scholar
  65. 65.
    Bains RD, Elbaz U, Zuker RM, Ali A, Borschel HG. Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach. Plast Reconstr Surg. 2015;135:397e–400e.CrossRefGoogle Scholar
  66. 66.
    Elbaz U, Bains R, Zuker RM, Borschel GH, Ali A. Restoration of corneal sensation with regional nerve transfers and nerve grafts: a new approach to a difficult problem. JAMA Ophthalmol. 2014;132:1289–95.CrossRefGoogle Scholar
  67. 67.
    Terzis JK, Dryer MM, Bodner BI. Corneal neurotization: a novel solution to neurotrophic keratopathy. Plast Reconstr Surg. 2009;123:112–20.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Section of Ophthalmology, Department of Head and Neck SurgeryThe University of Texas M.D. Anderson Cancer CenterHoustonUSA

Personalised recommendations