A Surgeon's Armamentarium for Ocular Management in Facial Paralysis: A Comprehensive Review.

OBJECTIVE: To review the current management paradigm of the eye in patients with facial paralysis. METHODS: A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "ocular," "facial," "synkinesis," "palsy," "neurotization," and various combinations of the terms. A total of 65 articles were included. RESULTS: Facial paralysis may result in devastating ocular sequelae. Therefore, assessment of the eye in facial paralysis is a critical component of patient management. Although the management should be individualized to the patient, the primary objective should include an ophthalmologic evaluation to implement measures to protect the ocular surface and preserve visual acuity. The degree of facial paralysis, lacrimal secretion, corneal sensation, and position of the eyelids should be assessed thoroughly. Patients with the anticipated recovery of facial nerve function may respond to more conservative temporizing measures to protect the ocular surface. Conversely, patients with expected prolonged paralysis should be appropriately identified as they will benefit from surgical reconstruction and rehabilitation of the periorbital complex. The majority of reconstructive measures within a facial surgeon's armamentarium augment coverage of the eye but are unable to restore blink. Eyelid reanimation restores the esthetic proportionality of the eye with blinking and reestablishes protective functions necessary for ocular preservation and function. CONCLUSIONS: Ocular preservation is the primary priority in the initial management of the patient with facial paralysis. An accurate assessment is a critical component in identifying the type of paralysis and developing an individualized treatment plan.

Outcomes of corneal neurotisation using processed nerve allografts: a multicentre case series.

BACKGROUND: Corneal neurotisation is a rapidly evolving procedure treating neurotrophic keratopathy. The variety of surgical techniques used and corresponding outcomes after corneal neurotisation are not well understood. This study describes the techniques and outcomes in the largest case series of corneal neurotisation using processed nerve allografts to date. METHODS: This is a retrospective case series of patients who underwent corneal neurotisation with human cadaveric processed nerve allografts. All patients had preoperative and postoperative description of best corrected visual acuity and measurement of corneal sensation. Comparative studies after stratification of techniques were performed. RESULTS: A total of 17 patients were identified. The cause of corneal anaesthesia was prior infection in eight cases, trigeminal nerve palsy in eight cases and ocular trauma in one case. There were no intraoperative or postoperative complications. Following neurotisation surgery, the time to first gain of corneal sensation and maximal gain of sensation occurred at a mean of 3.7 months (range 1-8 months) and 6.6 months (range 3-15 months), respectively. The mean preoperative and postoperative corneal sensation as measured by Cochet-Bonnet aesthesiometry was 0.36 cm (range 0-3.2 cm) and 4.42 cm (range 0-6 cm), respectively (p<0.01). Visual acuity was unchanged after neurotisation. There were no statistical differences in outcomes based on end-to-end versus end-to-side coaptations, donor nerve selection or laterality of donor nerve. CONCLUSION: Corneal neurotisation with processed nerve allografts is a safe and effective procedure. This study provides further evidence for the use of processed nerve allografts for corneal neurotisation.

Traumatic Optic Nerve Sheath Hematoma.

The aim of this report is to present a patient with traumatic optic nerve sheath hematoma (ONSH), a rare diagnosis with high potential for visual sequelae. This case involves a 41-year-old male who presented promptly following blunt trauma to the right eye and orbit that resulted in acute vision loss. Following computed tomography and ophthalmic examination, a diagnosis of ONSH was made and medical therapy with methylprednisolone was initiated. He reported significant improvements in visual symptoms following intravenous corticosteroid therapy. Although the patient reported significant improvements and had normal Snellen visual acuities in follow-up, he continued to have an inferior visual field defect at 1 week in the affected eye. ONSH causing subsequent localized compression of the optic nerve is a rare mechanism of traumatic optic neuropathy in patients following head trauma. The localized compartment syndrome of the optic nerve and subjective visual symptoms were relieved following corticosteroid therapy with no initial need for surgical decompression. Although central visual acuity returned to baseline, the patient had a persistent visual field defect and relative afferent pupillary defect.

Corneal Neurotization in the Setting of Facial Paralysis: A Comprehensive Review of Surgical Techniques.

ABSTRACT: Neurotrophic keratopathy is characterized by decreased corneal sensitivity, decreased reflex tearing, and poor corneal healing resulting in corneal injury. Without proper sensory innervation, the cornea undergoes continuous epithelial injury, ulceration, infection and eventually results in vision loss. In situations where patients have concomitant facial paralysis, such as after resection of a large vestibular schwannoma, the ocular health is further impaired by paralytic lagophthalmos with decreased eye closure and blink reflex, decreased tearing, and potential lower eyelid malposition. In patients with a dual nerve injury, the ocular surface is in significant danger, as there is increased environmental exposure in conjunction with the inability to sense damage when it occurs. Immediate recognition and care of the eye are critical for maintaining ocular health and preventing irreversible vision loss. The first modern corneal neurotization procedure was described in 2009. The ultimate goal in corneal neurotization is to establish sub-basal plexus regeneration via transferring a healthy nerve to the corneo-limbal region. Corneal neurotization can be achieved either via a direct transfer of healthy nerve (direct approach) or via nerve graft interpositions (indirect approach). This is an emerging concept in the treatment of neurotrophic/exposure keratitis and over the past decade multiple direct and indirect approaches have been described in the attempt to restore corneal sensation and to prevent the devastating outcomes of neurotrophic keratitis. Knowledge of these techniques, their advantages, and disadvantages is required for proper management of patients suffering from neurotrophic keratitis in the setting of facial paralysis.

CO2 Laser Lash Tilt Technique for the Treatment of Mild to Moderate Lash Ptosis and Augmentation of Upper Eyelid Blepharoplasty Results.

PURPOSE: To assess the safety, efficacy, and patient satisfaction of a newly described technique for the treatment of mild to moderate lash ptosis performed as augmentation to upper eyelid blepharoplasty. METHODS: Patient medical records for 27 consecutive cases of upper eyelid blepharoplasty between January 2016 and June 2017 and 19 consecutive cases of upper eyelid blepharoplasty with the laser lash tilt procedure between July 2016 and January 2017 performed by the senior author were retrospectively reviewed. Lash position in preoperative and postoperative photographs was graded in a randomized masked fashion on a 4-point scale by 5 oculoplastic surgeons. RESULTS: There was a significant improvement in mean lash position scores for the control group (0.52 ± 0.34, p < 0.001) with mean lash score improving from 1.14 ± 0.46 before surgery to 0.62 ± 0.46 after blepharoplasty alone. There was also significant improvement in mean lash position scores for the laser lash group (0.98 ± 0.52, p < 0.01) with mean lash score improving from 1.66 ± 0.62 before surgery to 0.68 ± 0.50 after blepharoplasty with laser lash treatment. The improvement in lash position seen in the laser lash group was significantly greater than the improvement seen in the control group (p = 0.001). There were no complications and all patients were satisfied with their results. CONCLUSIONS: Compared with upper eyelid blepharoplasty alone, the addition of the CO2 laser lash tilt technique provides a significant improvement in the upward tilt of the eyelashes as they emerge from the eyelid margin.

Minimally Invasive Corneal Neurotization With Acellular Nerve Allograft: Surgical Technique and Clinical Outcomes.

PURPOSE: To describe a minimally invasive surgical technique and its clinical outcomes with the use of acellular nerve allograft to re-establish corneal sensibility in patients with neurotrophic keratopathy. METHODS: Acellular nerve allograft was coapted to an intact supraorbital, supratrochlear, or infraorbital nerve and transferred to the affected eye. Donor nerve pedicles were isolated through a transpalpebral or transconjunctival approach. Retrospective evaluation of preoperative and postoperative corneal sensibility, ocular surface, and best-corrected visual acuity was performed in all patients. Mean follow-up period was 6 months (range: 3-10 months). RESULTS: Corneal neurotization with acellular nerve allograft was successfully performed in 7 patients with restoration of corneal sensibility and corneal epithelial integrity. In vivo confocal microscopy demonstrated increased nerve density in corneal stroma at 4 months after surgery. CONCLUSIONS: The use of acellular nerve allograft allows for a minimally invasive approach to successful corneal neurotization.

Adenocarcinoma of Pigmented Ciliary Epithelium in a Child With Aicardi Syndrome and Congenital Microphthalmia With Cyst.

A 5-year-old girl with Aicardi syndrome and microphthalmia with cyst of the OD presented with progressive enlargement of the cyst causing pain. Microophthalmia with inferior cyst (35 × 25 × 12 mm) was noted at birth, and Aicardi syndrome was diagnosed at 10 months by the presence of the classic triad of callosal agenesis, infantile spasms, and chorioretinal lacunae. She underwent enucleation with cyst resection, and subsequent reconstruction with a dermis fat graft. Histopathologic study revealed adenocarcinoma of the pigmented ciliary epithelium. Full-body metastatic workup was negative. Adenocarcinoma of the pigmented ciliary epithelium is an extremely rare eye tumor with only 4 documented cases in the literature, none arising in a microophthalmic eye with cyst. Aicardi syndrome is also a rare disease that has been associated with increased incidence of malignancy and ocular abnormalities, but has never been described in association with microophthalmia with cyst or with adenocarcinoma of the pigmented ciliary epithelium. Herein, the authors present a review of the case and relevant literature.

Endoscopic Corneal Neurotization: Cadaver Feasibility Study.

PURPOSE: The authors describe a cadaver feasibility study investigating a minimally invasive technique for corneal neurotization with the supraorbital nerve harvested endoscopically. METHODS: A cadaver study was performed to investigate the technical feasibility of corneal neurotization via endoscopic supraorbital nerve transfer to the corneoscleral limbus. RESULTS: Endoscopic corneal neurotization was successfully performed on each cadaveric hemiface. CONCLUSION: The use of an endoscope allows for a minimally invasive approach to corneal neurotization with the supraorbital nerve.

Endoscopic Corneal Neurotization: Technique and Initial Experience.

PURPOSE: The authors describe a minimally invasive surgical technique to re-establish corneal sensibility in a patient with neurotrophic keratopathy with the supraorbital nerve harvested endoscopically. METHODS: Pedicled contralateral supraorbital nerve was harvested endoscopically through small eyelid crease and scalp incisions and transferred to the affected eye. RESULTS: Endoscopic corneal neurotization was successfully performed with restoration of corneal sensibility and corneal epithelial integrity. CONCLUSIONS: The use of an endoscope allows for a minimally invasive approach to successful corneal neurotization with the supraorbital nerve.