Rehabilitation with the Enhanced Palpebral Spring
Robert E. Levine
Toe ocular manifestations of facial paralysis are a major source of both local and systemic disability. Locally, the in ability to blink and close the upper eyelid, coupled with the malposition of the lower lid, results in corneal drying and roughness, which in tum 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 be cause 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. Toe 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 suit able 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 be comes 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, how ever, 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 oftarsorrhaphies 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. Toe primary focus of this chapter is to explain the rehabilitative aspects of this enhanced palpebral spring procedure.
Patient Preparation
Toe patient is prepared and draped in the normal manner for lid surgery. Toe eye is protected with a scleral shell. Bupivacaine 0.5% mixed with an equal amount oflidocaine 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 offlid 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 ex pose 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 tar sus (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 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. 22A). 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 papillary 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 (DuPont. Wilmington, DE), 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 (Ptizer, Inc., Marietta, GA) 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 se cured 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.
Enhanced Palpebral Spring Implantation: Surgical Procedure
Currently, levator tightening is usually combined with the spring implantation. This procedure is referred to as “enhanced palpebral spring implantation.” Three double armed 5–0 Mersilene levator sutures are placed from tarsus through levator. The medial two of these sutures are placed through the Dacron patch as well (which helps fix ate it) prior to being continued into levator. Adding the levator tuck increases the blink speed and decreases the pseudoptosis. It also allows for more exact tension on the spring, by adjusting the tension on the levator sutures. With the patient seated, after the upper loop of the spring has been fixated, the levator sutures are tightened
to the maximum point short of becoming a tether for the lid. This is generally the best point of balance of forces. If the eye is overly open in primary gaze or if the blink speed is slowed, the levator sutures can be loosened.
Enhanced palpebral spring implantation is shown in Fig. 22.6. Deeper tissues overlying the spring are closed with 5–0 plain gut suture to ensure that the spring and the Mersilene sutures are well covered, Skin and muscle are closed with running 6–0 plain gut fast-absorbing suture or 6–0 Prolene suture.
Postoperative Care
Intravenous antibiotics are used intraoperatively, and oral prophylactic antibiotics are continued for 10 days. Intravenous steroids are also given intraoperatively, and a methylprednisone dose pack is used postoperatively. Antibiotic ointment is applied onto the wound twice daily until the wound is healed and skin sutures have been absorbed or removed. Ice packs are applied to the lid during the first 48 hours after surgery. Warm tap water compresses (or some other form of moist heat) are then substituted and continued until lid swelling subsides.
Rehabilitative Aspects of the Spring
Ocular Protection
The ability to blink provides the windshield wiper function required to spread tears across the cornea. This prevents the cornea from drying out during the day. In addition, being able to close the eye protects it at night without having to tape it shut. Because the spring works in any position, no extra pillows are required (Fig. 22.7).
Avoidance of Blurred Vision
As a result of increased ocular protection, less viscous lu bricants can be used. Especially in the cases of patients
who required ointment around the clock previously, their vision is significantly improved by being able to substitute moderate viscosity drops for ointment, or if tear function is normal, to no longer require supplemental lubricants?
Improved Cosmesls
It is not always possible to eliminate all the pseudoptosis that accompanies palpebral spring surgery. Whereas in the normal eye, closure is turned off when the eye opens, in this instance the downward force vector created by the spring is overcome by the upward force vector provided by the levator. In patients with weak levators, the levator cannot be strengthened (tightened) enough to fully over come the spring, and pseudoptosis results. Nevertheless, even the patient with pseudoptosis looks better than one with a significant tarsorrhaphy or a large weight (which also causes pseudoptosis, for the same reasons that the spring causes pseudoptosis).
Another aspect of the cosmetic improvement is the visibility of movement in an otherwise nonmoving half of the face. An active natural blink softens the impression of ab normality of that side of the face.
Improved Visual Field
Even a moderate lateral tarsorrhaphy can create a significant visual field defect in the direction of the lid adhesion. The author recalls an automobile mechanic whose major reason for wanting to get rid of his tarsorrhaphy and re place it with a spring was because he constantly bumped into equipment in his garage.
Allowing for Additional Eye Surgery
Patients whose facial nerve deficit resulted from an intra cranial tumor frequently have associated fifth and sixth nerve deficits. In the author’s experience with ~5,000 patients with facial paralysis, patients with a profound fifth nerve deficit have neurotrophic keratitis and require complete closure of the eye, even during sleep. They are not successfully protected with weights, and not infrequently present with a weight in place and a scarred cornea. Typically, they state no corneal surgeon wants to do a corneal transplant on them because the surgeon expects the trans planted cornea to also become scarred. Those with tarsorrhaphies in place are precluded from wearing the contact
lenses that may help protect their neurotrophic corneas long term.
In both scenarios, undoing the prior procedure and placing a spring often provides the protection they need. They can then convince the corneal surgeon that a penetrating corneal keratoplasty (corneal transplant) is a worthwhile undertaking. The author has had several patients who were previously not considered surgical candidates who underwent successful corneal transplantation after spring implantation. It was possible to restore the vision to blind eyes in the presence of facial paralysis, and they have subsequently maintained their corneal integrity.
In an analogous manner, strabismus surgeons have declined to straighten eyes in patients with combined sixth and seventh nerve paralysis who required continuous ointment use to protect the eye. They did not feel it worth while to straighten an eye that anyway would be blurred all day with ointment, precluding stereopsis. Once spring surgery was planned to eliminate the need for ointment, they proceeded to straighten the eye. (If both procedures are indicated, it is better to straighten the eye first, as that allows for more precise spring design.)
Allowing for Brow Elevation
Some patients with severe facial paralysis compensate in part for their lagophthalmos because the drooping brow helps push the upper lid shut. If one were to elevate the brow, the lagophthalmos would worsen. An isolated brow elevation in such a circumstance would there fore be contraindicated, leaving the patient with the brow droop deformity. However, if active lid closure is provided with a palpebral spring, the brow can be safely elevated, often at the same surgical session as the spring implantation.
Providing a Psychological Lift to the Patient
It is clear that improving cosmesis and therefore pro viding a more positive body image enhances a patient’s self-esteem and therefore provides a psychological lift. Less obvious is the implication that many patients have expressed: “Now that my eyelid is working again, 1 have more hope that my face will start working again, and find it easier to await recovery of facial nerve function.” Although the eyelid movement is a function of the spring, and not of recovery, what the patient experiences and feels is not always based on science. The feeling is real, and the author has heard patients express it many times.
Eliminating a Burdensome Routine
Some patients who could successfully manage their eye issues with an involved routine of lubricants and taping nevertheless spend a good part of their day caring for their eye. Improving the lid physiology by reanimating the upper lid with a spring allows them to use a much simpler routine.
Refocusing Their Attention
Patients who have to work at keeping their eye comfort able and out of trouble may have little time left for the other parts of their life. Tasks as simple as keeping water out the eye during a shower or wind out of the eye while
outdoors pose a real challenge. With a simpler manage ment routine and increased closure ability after spring implantation. they can resume a more normal lifestyle (Fig. 22.8).
Returning to the Mainstream of Life
Many patients experienced a multiplicity of the benefits described previously. With improved blinking, closure, cosmesis, self-esteem, and visual field, they could once again pursue their careers or their interests and direct their attention to their friends and family rather than themselves. An excerpt of a letter from a young woman who lived with facial paralysis from Bell palsy for a year prior to having a spring implant conveys well what the re habilitative effects of the spring can be:
“As I sit down to [write to you), tears are streaming down my face. There has not been a single day go by since I had my surgery with you that I am not re minded of the wonderful gift you have given to me. I can blink. First, my eye functions I I celebrate this every single day! I celebrate when I shower and the water isn’t in my eye I I celebrate that I can ski and bike and swim with no problems. I celebrate that I am not afraid of doing anything and I feel comfort able in social situations, I celebrate that the spring made it so I could drive again I I have four kids that I love to play with and I celebrate that they are not uncomfortable around me. Most importantly, I celebrate that this trial has made me a more compassionate and understanding person … You saved my eye and I get to see that sweet little spring every day and it puts a smile (half) on my face! You and Dr. did an amazing job with my face, even to the extent that I feel pretty again.”
