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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 181
Gold weight implantation as a treatment measure for correction of paralytic lagophthalmos


Department of Oral & Maxillofacial Surgery, Meenakshi Ammal Dental College & Hospital, Maduravoyal, Chennai, Tamil Nadu, India

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Date of Submission27-Sep-2010
Date of Decision12-Jan-2011
Date of Acceptance08-Feb-2011
Date of Web Publication25-Apr-2011
 

   Abstract 

Ocular complications from facial nerve paralysis can be quite devastating. Facial nerve paralysis results in cosmetic as well as functional problems. Paralysis of the upper eyelids leads to lagophthalmos, which results in incomplete closure of the lid over the cornea, leading to potential complication of corneal ulceration. The management of the affected eye in patients with facial palsy has been improved. Previously, ointment, eye drops, taping, partial or complete tarsorrhaphy was the primary treatment for inability to close the eyelid. Other mechanical techniques for reanimating lid closure are palpebral springs, encircling the upper and lower eyelids with silicone or fascia lata and temporalis muscle transfer. The most popular and widely used static procedure in facial nerve palsy is the upper eyelid gold weight implant. Gold eyelid implants are designed for the gravity assisted treatment of the functional defect of lagophthalmos resulting from facial paralysis. We report a case of a patient with facial paralysis who underwent gold weight implantation of the upper eyelid for correction of paralytic lagophthalmos.

Keywords: Facial palsy, gold weight implants, lagophthalmos

How to cite this article:
Manodh P, Devadoss P, Kumar N. Gold weight implantation as a treatment measure for correction of paralytic lagophthalmos. Indian J Dent Res 2011;22:181

How to cite this URL:
Manodh P, Devadoss P, Kumar N. Gold weight implantation as a treatment measure for correction of paralytic lagophthalmos. Indian J Dent Res [serial online] 2011 [cited 2014 Nov 1];22:181. Available from: http://www.ijdr.in/text.asp?2011/22/1/181/80002
Lagophthalmos, derived from the Greek word for hare, refers to the appearance of the hare, which sleeps with its eyes open. Generally, lagophthalmos refers to the inability of the eyelids to fully close. Various etiologic factors have been proposed for paralytic lagophthalmos; the most common include Bell's palsy, trauma to the seventh cranial nerve, neurosurgical procedures involving the cerebello-pontine angle, cerebrovascular accidents and previous eyelid surgery. [1] The ocular manifestations of facial nerve palsy include paralytic ectropion (sagging or rolling out of eyelid), incomplete eye closure, brow ptosis (drooping eyelid) and decreased tear production. These manifestations contribute to inadequate corneal protection which can lead to corneal ulceration, exposure keratitis and possible blindness. [2] Paralytic lagophthalmos can be managed depending on the etiology and the likely duration of recovery. A short duration problem can be managed by conservative measures with lubrication, taping and protective eye shields. If recovery is likely to be delayed, a more permanent surgical solution has to be considered. Various surgical techniques have been described with differing success rates; these include tarsorrhaphies, muscle transfers, fascia lata and silicone slings, palpebral springs and upper eyelid weights. [3] But the most common method of surgically treating lagophthalmos is eyelid loading. [2],[4] The authors present a case report of a patient who underwent insertion of a gold weight implant into the upper eyelid to correct lagophthalmos.


   Case Report Top


A 35-year-old female reported to our department with a complaint of inability to close the right eye completely [Figure 1]. She gave a history of excision of right cerebello-pontine angle schwannoma 10 years back, which resulted in complete facial nerve palsy. Following the palsy, she was advised ophthalmic drops, ointments and protective taping to provide comfort and to protect the cornea from trauma and drying. After 1 year of conservative treatment which did not provide desired result, she was again operated for dynamic rehabilitation with temporalis flap a year later.
Figure 1: Preoperative attempted eye closure

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At presentation, she had right lower motor neuron (LMN) facial palsy (House and Brackman, HandB grade 4) [5] with no evidence of associated hearing deficit. Symptoms associated with LMN palsy were paralytic lagophthalmos of right eye, loss of furrowing of over forehead and sagging of corner of mouth on smiling. Computed tomography (CT) of the brain revealed gliotic changes in the right cerebellar hemisphere with widening of the right cerebello-pontine angle, with no obvious enhancing area within.

For correction of paralytic lagophthalmos through static measures, commercially available 2.0-g, square-shaped, 22-k pure gold was used. This was wrought by a rolling machine and then trimmed to a desired shape. Wrought and trimming procedures are gradually performed until the defined shape and weight are attained.

The exposure of eye after maximum effort for closure by the patient was carefully noted (2 mm) and the dimensions of the tarsus (23 mm) were measured using a caliper and carefully reproduced on a paper model. Gold weights starting at 0.8 g with 0.2-g increments were placed serially over the pretarsal eyelid skin using paper tape with dual adhesive surface. The ideal weight was predefined as the one that achieved closure of palpebral fissure. The prosthesis was made by using the required weight of pure 22-k gold and subtracting 1.0 mm from the paper model. This helps one to confine the gold weight to the dimensions of the tarsus (whether in a child or an adult, irrespective of weight of the implant). The curvature was initially obtained by making an imprint of the outer surface of the eyelids using irreversible hydrocolloid dental impression material. Weight of 1.6 g was found to be adequate for the desired result.

After evaluation by the general physician and anaesthetist, the patient was taken up for surgery under general anaesthesia (GA). Marking was made in upper eyelid for incision. A 1 cm incision was made in the supratarsal crease [Figure 2] and continued through the orbicularis oculi muscle to the tarsal plate. The dissection was carefully carried out and a pocket was made over the tarsal plate [Figure 3] approximately of the size of the gold weight staying at least 2 mm superior to the lid margin. Two holes were made on the gold weight on both ends so as to facilitate stabilization at the time of suturing. Preweighed gold weight of 1.6 g was placed in the pocket medial to the mid-pupillary line [Figure 4] and was sutured to the tarsal plate with two partial thickness sutures of 5-0 prolene. The orbicularis oculi muscle was closed over the implant with resorbable sutures and the skin re-approximated with a running suture of 6-0 nylon. The postoperative sequelae were uneventful and the sutures were removed on the 7 th day with tight eye lid closure [Figure 5].
Figure 2: Supratarsal crease incision marking

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Figure 3: Sub-muscular pocket over the tarsal plate

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Figure 4: Implant in situ

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Figure 5: Early postoperative eye closure

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   Discussion Top


Gold weight implantation is the most commonly used static procedure for surgical correction of paralytic lagophthalmos. [2],[6] In the present case, a gold weight was inserted in the upper eyelid to allow closure by the force of gravity after accurate measurement of the weight required for complete closure.

Though various surgical options like tarsorrhaphies, canthoplasties, lid magnets, palpebral springs, muscle and fascia transfers and slings and nerve anastomosis exist for rehabilitation of paralyzed eyelid, the outcome and complexity of these procedures varies and the experience of the surgeon and case selection is critical in ensuring a favourable result.

Gold weight implantation has been shown by multiple authors to be a safe, reliable, reproducible and effective means of permanently rehabilitating paralyzed eyelids.It has gained widespread acceptance because of its low rate of complications and the relative simplicity of the surgical procedures.

Though other materials have been used to load the upper eyelid, gold is considered the material of choice because of its inertness, high density, malleability, non-allergic properties, relatively low cost (when compared to platinum) and also it provides good colour camouflage.


   Summary Top


Gold weight lid loading is a technique for the treatment of paralytic lagophthalmos and has become the standard in the management of paralytic lagophthalmos. The safety and efficacy of gold weight implants has been reported in several case series studies. Although the evidence is limited, implantation of gold lid weights (i.e., lid loading) has become an accepted and a widely used treatment for patients with paralytic lagophthalmos.

In conclusion, the use of gold eyelid weights is a simple, reliable and successful means of permanently rehabilitating paralyzed eyelids. Individual implants appear to decrease the postoperative complication risk and are effective in the management of paralytic lagophthalmos.

 
   References Top

1.Tower RN, Dailey RA. Gold weight implantation: A better way? Ophthal Plast Reconstr Surg 2004;20:202-6.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Kao CH, Moe KS. Retrograde weight implantation for correction of lagophthalmos. Laryngoscope 2004;114:1570-5.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.May M. The Facial Nerve. 2nd ed. New York: Thieme; 2000.  Back to cited text no. 3
    
4.Hontanilla B. Weight measurement of upper eyelid gold implants for lagophthalmos in facial paralysis. Plast Reconstr Surg 2001;108:1539-43.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.House JW, Brackman DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7.  Back to cited text no. 5
    
6.Dalkiz M, Gokce HS, Aydin A, Beydemir B. Gold weight implantation for rehabilitation of the paralyzed eyelid. Int J Oral Maxillofac Surg 2007;36:522-6.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
P Manodh
Department of Oral & Maxillofacial Surgery, Meenakshi Ammal Dental College & Hospital, Maduravoyal, Chennai, Tamil Nadu
India
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DOI: 10.4103/0970-9290.80002

PMID: 21525707

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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