Davos Courses

General Editor: Daniel Buchbinder

Authors: Damir Matic, John Yoo

Facial nerve - Irreversible paralysis, eye complex

back to CMF overview

Glossary

General considerations

Paralysis of the eye complex results in brow ptosis, inability to close the eye, and lower eyelid laxity.

Brow ptosis may result in asymmetry and loss of visual field (upper-lateral gaze).

Upper eyelid paralysis inhibits eye closure, resulting in corneal dryness and exposure.

Patients will experience excessive tearing, blurred vision, and pain. Prolonged corneal exposure without appropriate treatment may lead to ulceration and blindness.

Lower eyelid paralysis leads to lid laxity, which may result in ectropion. This further worsens tearing.

Lateral tarsorrhaphy
Main indication Skill Equipment
Corneal exposure Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Temporary and/or preemptive measure prior to definitive procedure to improve eyelid function and ensure corneal protection
  • Emergency measure when definitive treatment is delayed or there is possibility of imminent visual loss due to exposure
  • Salvage procedure when other treatments have failed
  • Poor or absent Bell's phenomenon

Advantages

  • Simple
  • Quick
  • Immediate result
  • Local anesthetic
  • Adjustable
  • Reversible

Disadvantages

  • Not dynamic
  • Poor cosmesis
  • Reduced visual field
Direct brow lift
Main indication Skill Equipment
Brow ptosis Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Eyebrow ptosis resulting in asymmetry with cosmetic deformity
  • Severe ptosis resulting in visual field impairment secondary to excess upper eyelid skin

Advantages

  • Simple
  • Quick
  • Immediate result
  • Local anesthetic
  • Repeatable
  • Low rate of relapse

Disadvantages

  • External scar
  • Not dynamic

Note: This is the most efficient way to raise the eyebrow when the frontalis muscle is paralyzed. Other techniques such as mid-forehead lift, coronal incision, and endoscopic brow lift require more surgery and have higher rates of relapse.

Upper eyelid weight
Main indication Skill Equipment
Symptomatic incomplete upper eyelid closure Basic surgical experience, no specialized skills Basic equipment only

Further indication

  • Failure to adequately close the upper eyelid resulting in epiphora and corneal exposure symptoms

Advantages

  • Simple
  • Quick
  • Immediate result
  • Local anesthetic
  • Adjustable
  • Reversible

Disadvantages

  • Not dynamic
  • Extrusion
  • Externally visible
  • Ptosis
Lower eyelid - Lateral strip canthopexy
Main indication Skill Equipment
Lateral lower lid laxity Some specialized surgical experience Basic equipment only

Further indications

  • Mild to moderate lower lid laxity resulting in scleral show or mild/moderate ectropion
  • Epiphora

Relative contraindication

  • Medial ectropion

Advantages

  • Reduces epiphora
  • Simple
  • Quick
  • Immediate result
  • Local anesthetic
  • Adjustable
  • Good cosmesis

Disadvantages

  • Static
  • Does not tighten lower lid medially
Lower eyelid - Tendon sling
Main indication Skill Equipment
Medial and lateral lower lid laxity Highly experienced and skilled surgeon Simple surgical and imaging resources

Further indications

  • Moderate to severe lid laxity with scleral show and ectropion
  • Medial and lateral ectropion

Relative contraindications

  • Young patients with mild laxity
  • Relative proptosis (positive vector)
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources