Facial paralysis causes flattening of half the face and loss of forehead wrinkles and horizontal lines. There is also a droopy eyebrow brow (ptosis), difficulty closing the eye (lagophthalmos), an inability to smile fully or whistle and the corner of the mouth is pulled down.
The most significant effects are on the eyes. The upper eyelid can be open a bit too wide (lid retraction) and the lower eyelid can sag and turn outward (ectropion), resulting in a watering eye, inability to close the eye and exposure or drying of the cornea. The eye can become red, vision can blur and sight is occasionally affected by ulceration and scarring (exposure keratopathy).
More unusual problems include losing the use of the nerve that controls sensation in the eye (trigeminal or fifth cranial nerve). This usually happens as a result of surgery on a large, benign brain tumour (an acoustic neuroma), which can affect both the facial nerve and the sensory nerve to the front of the eye.
These patients may suffer a lack of sensation on the surface of the eye (cornea), so that they cannot feel dryness, foreign bodies or injuries to the surface of the eye. This “neuropathic cornea” puts them at risk of developing a corneal ulcer and suffering severe or permanent damage to their sight.
Crocodile tears are another rare consequence of facial nerve paralysis. They occur when the damaged nerve tries to grow back along its old pathway but gets rewired to the tear (lacrimal) gland and to the muscles of the jaw. This results in tears when the patients chews (crocodile tears.)
Other consequences of a nerve regrowing in the wrong direction include involuntary closing of the eyelid and muscle spasms in the eyelid (aberrant regeneration of the 7th nerve), cheek and around the mouth (hemifacial spasm).
Due to the loss of the function of the muscle that supports the eyelid and pumps the tears, compounded by eyelid malposition and paradoxical tearing, the resultant watery eye may be a permanent sequelae of a facial palsy.
Frequently Asked Questions
How can facial palsy be treated?
This is the main stay of management.
Topical lubricant eye drops and ointment lubricate and wet the eye — there are many artificial tear preparations available, particularly the newer preparations like Systane, Celluvisc, Hyloforte & Optive which can be extremely effective.
Taping the eyelids shut at bedtime can be beneficial, but, if not done properly can allow the lid to remain open and unintentionally damage the cornea. A moist chamber created by using a piece of (kitchen) cling film, stuck to the bony (hard) prominences around the eye after generous application of lubricant ointment (lacrilube or viscotears) can be an effective option.
Some patients need to have their upper eyelid lowered with Toxin to paralyse the muscle which opens the eye — this allows the eyelid to drop over the surface of the eye and protect it.
Hemifacial spasm, crocodile tears and aberrant regeneration of 7th nerve can all be effectively managed with regular Toxin injections.
Tips To Make Your Eyes Comfortable
Mrs. Shah-Desai recommends buying special moisture chamber glasses (like 7eye by Panoptx) from www.dryeyeglasses.co.uk (phone 01392 411 363)
- Showering or hair washing can result in making the affected eye red & uncomfortable.
- Consider wearing ski goggles / swim goggles to protect your eyes for these routine tasks.
- Alternatively wearing a baby “Lil rinser splash guard” or “Clip safe shampoo shield” or a “shampoo cap or visor” can protect your eyes.
When there is a risk of corneal exposure from incomplete eyelid closure, surgery is a treatment option. It can also improve facial symmetry and eyelid function and reduce eye watering.
There are many different procedures:
Lower Eyelid Tightening (Lateral Canthal Sling).
The lower lid is shortened and re-attached a little higher to the outer bony rim, to allow the lower eyelid to sit in a better position, and thus may improve eyelid closure and comfort whilst reducing watering.
Stitching of the Eyelids
Stitching of the eyelids at outer corner (Lateral tarsorrhaphy), in the centre of the lid (central tarsorrhaphy) or at the inner corner (medial lee canthoplasty).
This is the surgical closure of different parts of the eyelid to reduce the length of the eyelid that is open, decrease evaporation and improve coverage of the eye. It is not the best aesthetic rehabilitative procedure and it can cause a blinkered effect to the vision towards the side where the surgery has taken place. It is therefore reserved for special cases and emergencies.
Medial Canthal Tendon Support
Stitches at the inner corner of the eye pull up the sagging lower eyelid.
Improving blinking (Gold weight or platinum chain to upper eyelid).
Placing a gold weight or thinner platinum chain in the upper eyelid can give a more animated expression and better closure of the upper eyelid, especially while blinking.
Drooping Eyebrow Surgery
This is known as brow ptosis correction. There are several different procedures to improve the position of a drooping eyebrow. Some of them involve incisions above the eyebrow (direct brow lift), or via the forehead or small incisions in the scalp (endoscopic brow lift).
The weight of the paralyzed mid-face or cheek can cause the lid to sag over time, and may require a mid face lifting to support the lower lid.
What are the potential risks & complication of surgical correction of upper lid retraction?
The risks of surgery include:
- Infection: this is very rare, occasionally the stitches may have an infective or inflammatory response, which settles with oral and topical antibiotics.
- Scarring (generally hidden in the skin fold). Normally stitches are visible for the first week, then, when they are removed, a faint scar is visible. The scar may seem a bit thickened & red for 6 to 12 weeks, becoming almost invisible after that period. Not every scar heals equally well. A thickened or reddened scar can be improved with silicone scar remodelling gel, but the treatment needs to be continues for months to have a good result.
- Large bruise or haematoma. This is minimised by avoiding heavy exercise for 2 weeks after surgery, stopping aspirin and other anticoagulants (if safe so to do) 2 weeks pre operatively, and regular use of ice packs. A haematoma may mean you have to go back into theatre to have the blood clot evacuated and then be re-stitched with the risk of a worse scar.
- Theoretical risk to vision. Any eyelid surgery carries the risk that an undiagnosed infection or bleed could damage the optic nerve. This is so rare that in comparison a normal car journey is a much greater risk to your vision.
- Asymmetry of eyelid shape, height or lid fold : this is rare, but can occur. Often asymmetry may be due to lid bruising and settles spontaneously as swelling resolves. Rarely, this may require revision surgery. Occasionally pre existing asymmetry of the face, eyebrow or eyeball position, may be responsible, however this will be discussed with you prior to the operation by your surgeon.
- Recurrence of eyelid malposition : This can occur early post surgery (3 months) or late (after a few years), due to weight of the heavy cheek/jowl. This will need to be corrected by re-operation.