16.1 Goals

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  To treat lagophthalmos due to dysfunction of the orbicularis oculi muscle by improving eyelid closure upon blinking and forced closure. Orbicularis muscle dysfunction commonly occurs as a result of facial nerve paresis or paralysis.

  
  
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  To provide corneal protection in cases of lagophthalmos, thereby preventing complications such as corneal ulceration and perforation.

  
  
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  To establish an acceptable aesthetic appearance.

16.2 Advantages

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  Upper eyelid weight placement allows for enhancement of dynamic eyelid function.

  
  
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  The results are immediate and lasting.

  
  
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  It is a straightforward, simple procedure to perform with rare need for readjustment.

  
  
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  The procedure is reversible; the weight can be easily removed if orbicularis function returns and the weight is no longer needed.

  
  
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  It is possible to simulate the predicted postoperative result prior to performing the procedure via weight fitting (see Preoperative Preparation).

  
  
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  It provides a better cosmetic result compared to other surgical treatments of lagophthalmos, including medial and lateral tarsorrhaphies, lower eyelid elevation, temporalis muscle transfer, and facial nerve repair/grafting.

  
  
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  The procedure is well tolerated with fewer complications compared to other techniques for dynamic eyelid reanimation, including silicone band and palpebral wire spring placement. ¹

  
  
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  It reduces the need for conservative treatments for exposure keratopathy, such as topical lubricants, eyelid taping, moisture chambers, and contact lenses.

  
  
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  Upper eyelid weight placement can be utilized in conjunction with procedures to correct the position of the lower eyelid such as medial/lateral tarsorrhaphies, lower eyelid elevation, or ectropion/retraction repair.

16.3 Expectations

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  After upper eyelid weight placement, the lid should have improved excursion with the patient in a vertical position.

  
  
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  Postoperative mild upper eyelid ptosis may occur following upper eyelid weight placement.

  
  
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  The effect on eyelid closure is gravity-dependent; therefore, lubricating ointment, eyelid taping, and/or careful patching at nighttime while the patient is supine may be necessary.

16.4 Key Principles

Upper eyelid loading via placement of a gold or platinum weight is a method of treating exposure keratopathy due to lagophthalmos, which is commonly the result of facial nerve paresis (weakness) or paralysis. The weight functions in a gravity-dependent manner, assisting the eyelid to fall and thus inducing eyelid closure when the levator muscle relaxes, as in downward gaze, blinking, and forced eyelid closure (Fig. 16‑1). The weight provides improved eyelid closure without causing complete ptosis or significantly compromising cosmesis. A functioning levator muscle allows the eye to open normally, usually with minimal ptosis.

16.5 Indications

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  Upper eyelid weight placement is an excellent first-line therapy for the treatment of exposure keratopathy due to facial nerve paresis or paralysis when maximal medical therapy is inadequate to maintain the health of the cornea. This applies to both acute, severe lagophthalmos and chronic cases unlikely to regain normal eyelid function.

  
  
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  Secondary procedure when other surgical methods of eyelid closure have failed (i.e., extrusion or fatigue of a silicone band or palpebral spring) or have provided an unacceptable aesthetic result.

16.6 Contraindications

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  Comatose or otherwise supine patients would not benefit from placement of an upper eyelid weight, given the weight’s effect is gravity-dependent.

  
  
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  A history of gold allergy is a contraindication to gold weight placement. Likewise, a history of allergy to platinum, iridium, or nickel is a contraindication to platinum weight placement.

  
  
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  Very thin skin with an atrophic orbicularis muscle is a relative contraindication, as the color and bulk of the weight may become apparent in the eyelid. ¹

16.7 Preoperative Preparation

Elements of the history and physical examination that are important to assess prior to placing an upper eyelid weight include blink frequency and completeness, severity of facial nerve dysfunction, corneal sensation, lagophthalmos, Bell reflex, and orbicularis muscle function. Understanding the etiology and prognosis for facial nerve recovery are also important in deciding whether temporizing measures should be employed versus this more durable surgical procedure.

The next step is selecting the appropriate weight. Although gold was traditionally favored, platinum has recently gained popularity, given its smaller profile due to increased density compared to gold and lower rate of tissue reaction. Platinum weights are available as chains or segments, which provide the ability to make adjustments by adding or removing a portion of the implant rather than exchanging the entire implant. ² Thin-profile gold and platinum weights are also available and are 0.6 mm in thickness compared to the traditional 1 mm thickness. Both gold and platinum weights range from 0.6 to 2.8 grams in 0.2-gram increments (Fig. 16‑2), are curved to match the curvature of the tarsus, and usually contain three holes for suture fixation.

Weight fitting is done prior to the procedure in order to determine the desired weight of the implant. A weight is affixed to the affected upper eyelid using adhesive, with the upper border of the weight just below the upper eyelid crease. A thin strip of tape may be placed horizontally so as not to obstruct eyelid opening. The eyelid position and completeness of eyelid closure are assessed both in the sitting and supine positions. If the weight does not provide adequate eyelid closure or produces an unacceptable amount of ptosis, then it is removed and the procedure is repeated using the next heavier or lighter weight, respectively. This process is continued until the lightest weight that provides optimal closure is identified. At rest, approximately 1 mm of upper eyelid ptosis is considered ideal. ³ Many patients do well with a 1.2 or 1.4-gram weight. Given that the next heavier weight may be necessary for complete eyelid closure, it is wise to have at least two weights available for the procedure. ¹