Rehabilitation with the Enhanced Palpebral Spring
The ocular manifestations of facial paralysis are a major source of both local and systemic disability. Locally, the inability to blink and close the upper eyelid, coupled with the malposition of the lower lid, results in corneal drying and roughness, which in turn causes severe discomfort and transient visual loss (which can elevate to permanent loss due to scarring). If the visual loss is severe, or becomes severe because of the necessity of filling the eye with lubricants, the patient is left with only the uninvolved eye available for use. Now monocular, stereo-acuity is lost. On a systemic level, being chronically uncomfortable, with the need to constantly be instilling lubricants, taping the eye, and functioning monocularly, without depth perception, is truly disabling. The patient′s entire day (and, in some cases, entire life) becomes focused around caring for the eye and keeping it comfortable.
In short-term paralysis cases, a bandage contact lens, lubricants, moisture chamber, support of the lower lid with tape, and taping the eye shut at bedtime often provide adequate management. However, the patients with long-term (6 months or more) facial paralysis generally require a surgical solution. For repositioning the lower lid, a suitable combination of canthoplasties, stents or slings, and/or malar suspension is effective.
Reanimating the upper lid is a formidable challenge. As a result, many clinicians have settled for tarsorrhaphy. Tarsorrhaphy does not reanimate the eye, but it does often protect it. It is, however, disfiguring and may add to the psychological load the patient with facial paralysis is already facing. In some instances, the tarsorrhaphy becomes a fixed tarsal window and fails to protect the eye. Except for a small lateral tarsorrhaphy, it precludes the adjunctive use of a bandage contact lens, which is often a great help in dry eyes and eyes with neurotrophic keratitis. It also limits the patient′s field of vision.
A popular approach to improving upper lid closure is implantation of a gold or platinum weight in the eyelid. In very mild cases of facial paralysis, this little boost may be enough to solve the problem. In more severe cases, however, a heavy weight is required, which is unsightly. More importantly, because eye closure with the weight is gravity dependent, it fails to close the eye at night, when the patient is supine. Patients are then left with still having to tape the eye each night or sleep with their head elevated with multiple pillows. Additionally, weights do not significantly increase blink speed.
Because of the limitations of tarsorrhaphies and weights, the author prefers the use of the enhanced palpebral spring procedure to reanimate the paralyzed upper eyelid. In the author′s experience with over 2,000 such procedures over the past 40 years, this procedure has been a major contributor not only to the immediate problem of eye closure, but to the patient′s rehabilitation. The primary focus of this chapter is to explain the rehabilitative aspects of this enhanced palpebral spring procedure.
Patient Preparation
The patient is prepared and draped in the normal manner for lid surgery. The eye is protected with a scleral shell. Bupivacaine 0.5% mixed with an equal amount of lidocaine 2% with epinephrine is infiltrated along the lateral two-thirds of the upper lid fold. This mixture of anesthetic is also infiltrated along the tarsus at the center of the upper lid and along the lateral orbital rim. Care is taken when injecting to avoid distortion of lid anatomy or levator function. Basal sedation, given preoperatively, should be limited to short-acting agents that will not interfere with the patient′s state of consciousness during the procedure, as cooperation is needed to open and close the eyes and to sit up on the operating table.
Implanting the Spring
With a protective scleral shell in place, an incision is made along the lateral two-thirds of the lid crease and carried across the orbital rim laterally ( Fig. 22.1 ). Dissection is carried downward at the medial end of the incision to expose the tarsal plate. Dissection is also carried upward and laterally to expose the orbital rim.
A 22-gauge blunted spinal needle with the stylette in place is passed from the medial end of the dissection to emerge laterally in the plane between orbicularis and tarsus ( Fig. 22.2 ). The passage should be performed overlying midtarsus. The needle is angulated slightly downward at its lateral extent. The exit of the needle tract should be close to lateral orbital rim periosteum. The lid is everted to confirm that the needle has not inadvertently perforated the tarsus. The previously prepared wire spring (fashioned pre-operatively using 0.01 inch 35NLT wire from Ft. Wayne Metals, Ft. Wayne, IN) that has been sterilized, either by gas or low-temperature sterilization, is passed through the needle and the needle is withdrawn.
A cross-section of the lid illustrates placement of the needle over the midtarsus in the plane between the tarsus and orbicularis ( Fig. 22.3 ). The wire spring should be resting on the epitarsal surface but not pressing on it.
The scleral shell is removed and the fulcrum of the spring is brought into the desired position along the orbital rim ( Fig. 22.4 ). The spring should be placed in a position where its curves conform perfectly to the eyelid contour. The fulcrum of the spring is secured to the lateral orbital rim periosteum with three 4–0 Mersilene sutures (Ethicon, Inc., Somerville, NJ), taking an extra bite of the periosteum with each stitch. The lower limb of the spring should terminate at the point corresponding to the pupillary line in primary distance gaze. Loops are fashioned at each end and the spring is cut to size. The loops should be flat and tightly closed to leave no sharp edges. The medial loop is enveloped in 0.2-mm–thick Dacron patch material (Bard DeBakey, Tempe, AZ), to which it is secured by means of three 7–0 nylon sutures tied internally. The Dacron patch material is creased in a Gelfoam press (JEDMED, St. Louis, MO) before surgery and autoclaved with the other instruments. The folded Dacron envelope is cut to size at surgery. The crease in the patch material should be directed downward so that the spring and patch together provide a smooth inferior surface. The loop at the end of the inferior arm is directed upward for the same reason. Suturing of the loop to the Dacron is facilitated by resting the Dacron on a retractor.
The end of the spring with its Dacron envelope is secured to the tarsus with 7–0 nylon sutures ( Fig. 22.5 ). In time, the end of the spring will be reinforced to the tarsus by granulation tissue integrating into the Dacron patch.
The upper loop should be perpendicular to the fulcrum so that it can press against the superior orbital rim. The upper loop of the spring is secured to the undersurface of the superior orbital rim periosteum with three 4–0 Mersilene sutures. An extra bite of the periosteum may be taken in each stitch before tying. When placing sutures to secure either the fulcrum or the upper loop of the spring to the orbital rim periosteum, it is safer to sew in the direction away from the globe.
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