Management of Lagophthalmos in Leprosy M. LENNO X, B. SC., F.R.C.S. ( ENG. ) , F. R.C.S. (EDIN.) w. C/o. The British Leprosy ReliefAssociation, 8 Portman Street, London I W.

Lagophthalmos, or paralysis of the orbicularis effort to keep it closed. Degrees of lag in excess orbis muscle, may result from injuries to the of mm. are easily seen, and in the fully 0.5 facial nerve, non recovery of Bell's Palsy, and developed condition even the upward roll of the leprosy. Syphilis and Poliomyelitis are rare eye may fail to bring the cornea fully under causes. Exposure conjunctivitis, keratitis ectro­ cover of the upper lid. Lag exceeding 12 mm. is pion and dacrocystitis are common complica­ not uncommon. In these conditions exposure tions. About one quarter of leprosy cases have changes are likely to be found over the lower corneal anaesthesia, and about one in ten show one third of the cornea, which becomes dry and ectropion or lacrymal sac infection. In endemic vulnerable. areas the overwhelming majority of cases, and much consequent eye morbidity, are due to General Nlanagement leprosy. Many eyes are encountered with minor lagoph­ The combination of lagophthalmos with thalmos, adequate corneal coverage, and free­ corneal anaesthesia is particularly dangerous, dom from complications. Since most mild cases and requires urgent treatment. This is seen progress to total paralysis, they should be seen most often in long-standing lepromatous patients regularly, and be provided with a suitable oil It is much less common in the tuberculoid and and a mildly antiseptic lotion (see below). dimorphous forms. In these, lagophthalmos is a Protective spectacles may be required for special hazard of reaction, particularly in occupational hazards. Anaesthesia of the hands pati.:nts with large facial macules. requires specific use of the eyes for avoidance of Leprosy neuritis interrupts conduction in the injury, and any risk to vision is therefore doubly facial nerve either just distal to the stylomastoid dangerous. foramen (giving an extensive facial paralysis), Many patients suffer from vitamin deficien­ or the zygomatic branches are affected where cies and it is reasonable to give supplements of they lie superficially in the cheek. Occasionally vitamins A and C. Exposure changes are treated enlarged branches may be palpated against the energetically along the usual lines. Ulceration zygoma. The Proprioceptive fibres of the facial of the cornea is an emergency and must be muscles travel in the fifthcranial nerve and make treated by the method indicated for the particu­ multiple connections with motor twigs within lar case. Once complications are controlled, the facial muscles. There thus exist anatomical the management becomes that of the uncompli­ connections between sensory and motor nerves cated case. A mild antiseptic lotion (e.g. ! oz. in the face, which may permit M.leprae from zinc in % boracic acid lotion, tds.) should be 5 the sensory nerves to spread into the facial instilled during the day and sterile castor oil nerve. This may explain the association between drops at night, to prevent drying during sleep. large facial macules and lagophthalmos. Attention may now be directed to the paralysis.

Signs and s..ymploms Management of Paralysi.r Reduction in the frequency of blinking may be Lagophthalmos may be 'acute', subtotal, or noted. Excessive watering from profuse reflex complete. tear secretion and subclinical ectropion, and burning pain, are prominent symptoms. Very 'Acute' Lagophthalmos: This is lagophthalmos of early lag can be detected by gently attempting sudden onset, usually associated with reaction. to open the eye manually against the patient's A small proportion of these cases recover when

Management oj Lagophthalmos 151 the reaction subsides : the majority, unfortu n­ an abso lute in dication fo r early opera tion . The ately, do not. If the case is seen early, the pros ­ methods at presen t available are : pects for recovery can be enhanced by exhibiting steroids . A course commencing wi th a large dose I. Tarsorrhaph y 2. Static eyelid slings (e.g . Prednisolone 60 mgm . daily orally) and tapering down to nil wi thin 14-21 days, is 3. Sommerse t's opera tion useful in prac tice , and avoids some of the dan­ 4. Temporalis transfer gers inheren t in steroid therapy. These are not Tarsorrhaph y is a simple procedure, and is inconsiderable, and it is sugges ted tha t any who reversible . Its main uses are : reac tion cases wi th are unfamiliar wi th these drugs should secure wide lag where there is hope of recovery, and the advice of a physician before prescribing the highly positive or elderly pa tien t. It does them . not preclude a later temporalis transfer . The While awai ting the ou tcome , the general static eyelid sling may be considered for the measures noted above are ins ti tu ted . A severe old or unin telligen t pa tient wi th lower corneal lag may require support of the lower eyelid by changes . The orbi tal fissure is permanen tly strapping, and very occasionally a temporary narrowed , though over the long term there may tarsorrha phy is require d. Af ter ten days , be some recurrence of sagging of the lower lid . galvanic stimulation may be star ted in an effor t Sommerset's operation consis ts of running a silk to minimise atrophy of denervated muscle or nylon suture round the lid margins . The fibres . disadvantage is the risk of infection , and some There is no general agreemen t about how residual orbicularis ac tion is necessary to effec t long one should wai t before abandoning hope of closure . recovery . A practical rule is to treat par tial The operation of temporalis musculofascial recoveries as described below, and to advise sling, devised by Gillies , has proved to be of surgery where no recovery commences within immense benefit in lagoph thalmos . It is the three months . procedure of choice in the majority of cases, and Subtotal Paralysis: This frequen tly results from will be described more fully. The technique is incomple te recovery of an 'acute' lagoph thal­ not difficul t to mas ter (See Antia, 1963 : Andersen mos . Residual mo tor ac tivi ty is present in the 1961) and deserves to be more widely known . orbicularis, and the lag is insufficien t to uncover A modifica tion which avoids reversing muscle the cornea . These cases jus tif y a trial of physio ­ polari ty has been described by Johnson (1962). therapy aimed at hyper trophying fibres wi th Pre-opera tively, the conjunctival sac and the in tac t innervation . The pa tient prac tises eye lacrymal sac should be free from infection , and closure many times a day, and courses of faradic patency of the nasolacrymal duc t is confirmed stimulation are given . Progress is assessed by by syringing . The scalp is comple tely shaved and periodically measuring the gap be tween the the fieldis prepared wi th 1 % ce trimide solution . eyelids . Oil and antise ptic drops are presc ribed . The opera tion is carried ou t under local A regular and careful watch must be kept for infil tra tion anaes thesia (t% xylocaine wi th exposure changes in these cases as well as in 1 : 200,000 adrenaline) , or light general anaes­ those wi th 'acute' lag . Sommerset and Sen (1957) thesia . The head is draped leaving the side of the warn about assuming tha t partial recoveries head and the upper face exposed . afford adequa te pro tection for the eye . They Figures 1 to 4 illus tra te stages of the operation . advise that 'all cases showing any degree of Incision A, wi thin the hair line, extends from the weakness of the lid movements should , therefore, upper border of the zygoma to 2 cm. above the be carefully watched for involvemen t of the superior temporal line . It is deepened to the cornea, and a tarsorrhaphy (la teral or medial) temporal fascia , wh ich is ex posed by retrac tion operation performed as a preventa tive measure of the wound margins. A strip of fascia is ou t­ in mos t cases' . In these C'ircums tances, however , lined by a pair of ver tical incisions half an inch it would be func tionall y and cosmetically more apar t, star ting below at the zygoma and ending appropria te to perform a temporalis transfer. in perios teum half an inch above the superior To tal Paralysis: Total paralysis requires temporal line . The stri p is eleva ted from the surgery . The presence of corneal anaes thesia is subjacen t temporalis muscle but is lef t attached 15'2 Leprosy Review FIG. I FIG. 2 Incisions Fascial strip outlined and elevation commencing

FIG. 4 FIG. 3 Eyelids tunnelled, lower eyelid slip in situ, upper eyelid Single fa scial strip divided into two thin slips slip ready for passing above. (Fig . 2) . At the lower end the fascia continuity with the fascial strip . The muscle is divides into superfic ial and deep layers inserting freed sufficiently to allow the fascia to reach to int o the inner and oute r margins of the superior the inner canthus on swinging the slip fo rwards. surface of the zygomatic arch . The space be­ Its nerve and vascula r supply , enteri ng deeply tween the lay ers contains vessels ; this configura­ and below, is not disturbed . tion may occasion a little difficulty in freeing the From incision A a subcutane ous tunnel is strip at the lower end , if forgotten . The upper fashioned to a cm . incision at the oute r canthus 1 end of the st rip is freed by a transverse inc ision (incisi on B) . The slip is placed in this bed, so that th rough the peri osteum , followed by downward the musculo-fascial junction lies at the oute r stripping with a peri05teal elevator. This process canthus. The junction can be reinforced with a also elevates temporalis muscle from the bone of single suture if desired . The fascia is delivered the superior temporal fossa, and by splitting the through the wound , having been divided longi­ fibres on each si de a muscle slip is fa shioned in tudinally into two strips (Figs. 3 and 4) . A Management of Lagophthalmos 153 I cm . vertical curved incision is made, 5 mm . tarsorrhaphy may be released later when the medial to the inner canthus (incision C), and transfer has developed its fu ll power . by careful blunt diss ection the medial canthal ligament is defined . Damage to the more deeply Causes ofSuboptimum Results placed lacrymal sac must be avoided . The inner The incidence and causes of suboptimum results and outer incisions are joined by narrow sub­ are illustrated by analysis of the results of 43 cutaneous tunnels fa shioned by delicate blunt eyes (30 patients) operated under the South subcutaneous dissection close to the margins of Indian Peripheral Surgical Assistance Scheme . both lids . This is fa cilitated by previous infiltra­ The operations to be reported were performed tion with anaesthetic solution : occasionally by six different surgeons in seven different hos ­ small horizontal counterincisions at the mid pitals, employing the technique desc ribed points of the lid margins are helpful . The fa scial above . strips are passed through the tunnels, and then deep to the medial canthal ligament (Fig . 4). Material and Methods With high tension applied to th e lower eyelid One patient could not be traced . Five with a slip and the slack taken up fr om the upper slip, fo llow up of less than three months are also the upper eyelid wil l overlap the lower, and in excluded, although all were graded good or this position the slips are sutured to each other excellent . Thus 37 operations on 24 patients are and to the medial canthal ligament . available fo r report . Ages varied fr om 23 to After checking haemostasis, the incisions 50 years ; length of fo llow up varied fr om three are closed without drainage : a pressure dress ­ months to two years . Pre-operatively, the widths ing is applied to the temporal wound . A lit tle of the orbital fissures (on attempting closure) antibiotic ointment is injected between the varied between five and 15 mm . the majority eyelids . being about 1 cm . No patient in this series had corneal anaesthesia, but in 50% exposure Post Operative Management changes, usually mild, were present .

For IO days the patient takes fluids only by Since there is no accepted standard fo r grad ­ mouth, and soft diet fo r a fu rther IO days . ing the results of this operation, a method based Normal diet is then allowed, and chewing is upon attainment of effective corneal coverage encouraged . The patient is given a piece of (the main objective of surgery) was devised . sponge rubber to chew upon . The sutures around The criteria are : the eye are removed at fo ur days, the temporal Excellent -complete closure on moderate sutures after a week . Eyelid oedema absorbs in effort 3 or days . After commencement of chewing 4 Good -slight lag present on moderate exercises fu ll volun tar y closure is obtained in 2 to 4 weeks . The patient must be taught to effort, but no lag present on fo rced effort clench his teeth periodically while out in the Fair -lag persists, but the cornea is open to mimic the blink reflex . Later the eye will covered on effort remain closed during sleep . Poor -lag persists, and the cornea is not adequately covered on effort. Lagophthalmos and Ectropion The presence of ectropion impar ts special diffi­ 'Moderate effort' is the degree ofeffort adopted culties to lagophthalmos repair . Great care must by a patient when asked to close his eyes . It be taken to place slings exactly along the lid is usually submaxima!. margin ; fa ilure to do this may aggravate the eversion . It is recommended that a standard Results ectropion repair be performed first, and that the Thirty eyes were graded good or excellent, and seven fa ir or poor ( 8 1 % 19% respectively) . paralysis be dealt with at a second operation . & Otherwise, tarsorrhaphy is a safer procedure . Particular interest attaches to the 19% of For lag with mild ectropion, lateral tarsorrhaphy unsatisfactory results, which are detailed in the at the time of temporalis transfer is advised . The fo llowing table. 154 Leprosy Review No . of Post Operative Remarks Follow Patient ryes Complications Up

V.R . 2 Canthal Sepsis A beggar : did not co­ 6/12 2 eyes operate post-operatively. On effort could achieve Poor corneal coverage, but made no effort to use his transfer except when supervised.

A Canthal Sepsis Patient co-operated well, 6/12 but slings lost tension.

V. nil Previous tarsorrhaphy 6/ [2 released at time of trans­ fe r: tension probably insufficient ab initio. Fair A.N . Canthal Sepsis Loss of tension

B. 2 Canthal Sepsis Loss of tension in both I year eyes. Both improved to 'Fair' by exploring and re-attaching the slips which were fo und to have pulled back into the eyelid.

Infection at incision 'C' was the commonest complication. It occurred in six of the seven eyes graded fair and poor, but it also occurred in five other eyes which were graded 'good' . It is therefore not necessarily prejudicial to a satis­ factory result (fig. 5), but in three of the patients listed in the table it was the most likely cause of loss of tension and consequent downgrading. In case B, subsequent exploration revealed that the slips had failed to attach to the medial canthal ligament, and had, in fact, pulled back into the eyelids .

Discussion It will be noted that a 'good' result is permitted

2 or 3 mm. of lag on moderate effort, providing that the cornea is covered. In a number of cases the lag was apparent and persisted from the FIG. early weeks, and it must be assumed that the 5 initial tensioning was too low. This may have Canthal sepsis with residual stitch granulomas. Neverthe­ contributed to the result in patient V. ('Fair') . less Left eye graded Excellent. Right eye down graded to because of 2 mm. lag and trace of eversion of the Good This emphasises the need for high tensioning at lower lid. Slings Inust be placed accurately along the operation : over tensioning is really not possi ble . margins of the lids Management rif Lagophthalmos 155 Since canthal sepsis was the commonest 'excellent' initially, to be downgraded to 'good ' complication the placing of incision C we ll subsequently with the recurrence of a small medial to the canthus must be stressed . A small amount oflag (Fig . 7) . Possibly these cases were flap of skin and subcutaneous tissue is fo rmed not tensioned adequately, and it is not unrea­ which falls back into place when retraction is sonable to wo nder if they may require further released . The canthal skin is very thin ; it must downgrading at a fu ture date . Because of the be handled with the utmost gent leness , and be possibility of late deterioration, it is reasonable sutured meticulously . to advise patients to per form specific exercises The causes of failure in this series may be regularly each day, after discharge . summarised as fo llows : ( 1 ) Loss of tension , occasionally fo llowing Summary and Conclusion canthal sepsis, but not specifically associated A successful temporalis transfer gives support to with this complication. the paralysed lower lid , and repositions the (2) Inadequate tensioning at the time of puncta fo r draining tears . It provides voluntary operation . Failure to obtain su fficient tension at power fo r closing the orbital fissure, and pro­ opera tion resulted in a number of cases being motes reversal ofexposure changes in the eye. It downgraded from 'excellent' to 'good' . substitutes for the blink reflex , since the eyelids move with every contraction of the temporalis (3) Failure to co-operate in aftercare: and muscle : and resume their wiping and lubricat­ physiotherapy . Early chewing might conceivably ing ac tions . Effective protection is afforded to pull the slips free from the medial canthal liga­ the cornea rendered insensitive by leprosy . The ment . cosmetic effect is pleasing ; the risks of blindness (4) Error of Selection . Case V.R., a beggar , are minimised . would have fa red better with a tarsorrhaphy A series of 37 opera tions is presented . In­ (Fig . 6). fection of the medial canthal wound is the Andersen (196 1 ) reports 80% success in a series commonest complication . Nevertheless, the of 10 eyes with one to three months fo llow up . operation carries a satisfactory success rate in the Several cases in the present series were graded hands of non-specialised surgeons , providing the

FIG. FIG. 7 6 Case V.R. Maximal effort just covers the corneae, but Maximal effort gives fu ll closure. Moderate effort leaves patient did not achieve this degree of closure unless mm. of lag. Graded Good. (Left eye) 2 supervised. Graded Poor 156 Leprosy Review tec hnique and post-operative regime are care­ John Vinookumar Esq ., to whom my spec ial fu lly fo llowed . thanks are due. It the author's hope that the operation will is be used more fr equently. REFEREN CES ANTIA, N. A. Reconstruction of the Face in Leprosy. ACKNOWLEDGEMENTS Annals of Royal College of Surgeons. 32, (1963), 7 I. ANDERSEN, J. G. Surgical Treatment of Lagophthalmos in It is a pleasure to acknowledge the interest and Leprosy, by the Gillies Temporalis Transfer. British enthusiasm of all those surgeons who partici­ Journal ifPlastic Surgery, (1961), 339· 14, pated in the peripheral surgical project in JOHNSON, H. A. A Modification of the Gillies Temporalis South India , and who permitted me to examine Transfer for the surgical treatment of the lagophthalmos and comment upon their cases . Much of the of Leprosy. Plastic and Reconstructive Surgery. 30, (1962), 378. SOMMERSET, E. J. and SEN, N. R. Leprosy in India. (1957), 29, fo llow up data was collected and recorded by 142•

Management ofLago phthalmos 157