Impact of early eyelid weight placement on the development of synkinesis and recovery in patients with idiopathic facial paralysis.

PURPOSE: Determine the impact of upper eyelid weight placement at 3 months post onset of idiopathic facial paralysis (IFP) on the recovery of facial function in patients with lagophthalmos. METHODS: This is a retrospective review of patients with incomplete recovery of IFP-defined as a Sunnybrook Facial Grading Scale (FGS) score of less than 100, 3 months after onset. Only patients with FGS and Facial Clinimetric Evaluation (FaCE) scores recorded at 3 and 12 months were included. Patients were categorized into 3 groups: Group A, lagophthalmos with eyelid weight placement; Group B, lagophthalmos without eyelid weight placement; Group C, complete eye closure (CEC) without eyelid weight placement. The eye comfort domain and composite score of the FaCE questionnaire were analyzed. Voluntary eye closure, synkinesis with eye closure, overall synkinesis and the composite score of the FGS were also analyzed. Paired two-tailed t-test was used to evaluate the data comparing the 3 and 12 month FaCE and FGS scores within and between the 3 groups. RESULTS: The change in composite FGS score significantly increased from month 3 to month 12 in Group A as compared to Group B (37 vs 4.25, P = 0.01). While Group A had significantly lower eye comfort (-12.5, P = 0.01), voluntary eye closure (-1.75, P = 0.05) and overall FGS scores (-28.75, P = 0.04) at 3 months compared to those in Group C, there were no differences between these two groups at 12 month follow-up. CONCLUSIONS: For patients with lagophthalmos at 3 months, early eyelid weight placement may lead to improved facial function at 12 months.

A Prospective Randomized Comparative Clinical Trial to Analyze Pain and Surgical Outcomes Between Frontal Nerve Blocks and Subconjunctival Anesthesia for Conjunctival Mullerectomy Resection.

PURPOSE: Conjunctival Müller's muscle resection (CMMR) is a posterior approach surgical technique to correct blepharoptosis. The purpose of this study is to compare patient-reported pain scores and surgical outcomes for patients who received 2 different anesthetic techniques during CMMR, frontal nerve block and subconjunctival injection. METHODS: A prospective randomized comparative clinical trial enrolled 33 CMMR subjects from one tertiary eye center. Patients undergoing unilateral CMMR were randomized to receive either frontal nerve block or subconjunctival injection. For patients undergoing bilateral CMMR, each side was randomized to one of the injection techniques. Upper eyelid margin reflex distance was measured and recorded for each eye before and after surgery. Patients' pain scores were quantified using the Wong Baker Pain Scale. Subjects quantified their pain during, immediately after, 12 and 24 hours after surgery. RESULTS: Twenty-four bilateral and 9 unilateral cases were enrolled in the study. Twenty-two (92%) subjects were female, and the mean patient age was 69 ± 12 years. The mean margin reflex distance was 1.1 mm preoperatively, which increased to 3.5 and 3.6 mm 2 months postoperatively in frontal nerve block and subconjunctival injection groups, respectively (p value <0.0001). Both paired and nonpaired analyses demonstrated no significant difference in the pain score reported by the patients or the surgical outcomes between the 2 anesthesia techniques at any time during or after the surgery. There were no anesthetic-related complications. CONCLUSION: There was no statistically significant difference in pain scores or surgical outcomes in patients receiving frontal nerve block compared with those receiving subconjunctival injection during CMMR surgery.

Three-Snip Punctoplasty Outcome Rates and Follow-Up Treatments.

PURPOSE: To demonstrate the success rate of three-snip punctoplasty (TSP) for the treatment of punctual stenosis and to evaluate the need for additional treatment after TSP. METHODS: A retrospective chart review was conducted of all patients undergoing TSP by a single surgeon at Bascom Palmer Eye Institute from January 1, 2006 to January 1, 2010. Outcome measures include the persistence of symptomatic epiphora, the need for additional surgical interventions, and postoperative time required until complete resolution of symptoms achieved. RESULTS: Primary TSP resulted in an 86% success rate with resolution of symptomatic epiphora without further surgical intervention. Seven eyes (14%) required secondary TSP with or without stent placement. All 6 eyes with TSP with stent placement achieved functional success within an average of 6.8 months (stdev 6.83) from the first TSP. The one eye that was not stented during secondary TSP required a tertiary TSP with stenting and achieved functional success within the 1 month of the final procedure. CONCLUSION: Primary TSP showed an 86% success rate with the resolution of tearing by an average of 1.2 months post-operatively. Membrane formation or scarring over the surgical site required an additional TSP with stenting in 14% of patients. All 50 eyes eventually achieved functional success. TSP alone as a primary procedure is a safe, relatively simple, and effective treatment of epiphora caused by punctual stenosis. Stenting should be explored as an adjunct to this procedure if primary TSP alone does not produce resolution of symptoms.

Lacrimal canalicular transplantation with composite eyelid graft.

PURPOSE: To describe a new surgical approach for secondary repair of canalicular lacerations using a full-thickness en bloc eyelid transplantation. METHODS: This a single case report of full-thickness en bloc eyelid transplantation. The patient presented with symptomatic epiphora several years after traumatic laceration of the left lower canalicular system. The canalicular system of the right upper eyelid, including the punctum and a section of the canaliculus, was resected and transplanted to repair a dysfunctional left lower eyelid. The primary outcome measure was the functionality of the transplanted canalicular system. RESULTS: The transplanted lacrimal system was patent by irrigation at multiple visits postoperatively. In addition, the patient was asymptomatic and was pleased with the cosmetic result. CONCLUSION: This is the first reported case of successful canalicular transplantation. Although a single case report, the authors anticipate future success with this technique.