Levator Recession for Management of Lagophthalmos and Corneal Exposure in Patients with Facial Palsy

Purpose: Exposure keratopathy due to lagophthalmos is the most important ophthalmic consequence of facial palsy. Various procedures are used to protect the cornea from exposure, including tarsorrhaphy and gold weight insertion. Recession of levator muscle, a technique originally suggested for treatment of upper lid retraction in thyroidophthalmopathy, can potentially decrease the severity of corneal exposure by reducing margin-reflex distance 1 (MRD-1). The purpose of this study is evaluation of effects of levator recession on lagophthalmos in facial palsy. Methods: This is an interventional, non-comparative case series of consecutive patients with exposure keratopathy due to facial nerve paralysis who presented between 2014 and 2016. Levator recession was performed through lid crease incision. Aponeurosis of levator was exposed and maximally recessed. Additional procedures were performed on a case by case basis, including tarsorrhaphy and lateral tarsal strip (LTS). Pre- and postoperative measurements of MRD-1 and lagophthalmos were compared using paired T-test. Results: Forty seven patients (21 men and 26 women) were enrolled with an average age of 55.5 years. Mean follow up was 13 months (range, 6-36 months). The most common etiology of facial paralysis was Bell’s palsy (25 cases), followed by motor vehicle accident (10), brain tumor surgery (5) parotid surgery (3), congenital (2), cerebrovascular accident (1) and herpes zoster infection (1). No additional procedures were performed in 8 patients. Tarsorrhaphy was performed in 38 patients, with 10 of whom having had LTS, one having canthorrhaphy, and one having midface lift. Lower lid retractor lysis was performed for one patient. Mean MRD-1 decreased from 5.0±0.4 to 3.9±0.6 mm (p<0.001) and mean lagophthalmos decreased from 3.7±1.0 to 1.9±0.8 mm (p<0.001). Conclusion: Recession of levator muscle was effective in reduction of MRD-1 and lagophthalmos in facial palsy patients. This procedure can be added to the surgical armamentarium for management of facial palsy patients with lagophthalmos.