A clinical algorithm for the management of facial nerve palsy from an oculoplastic perspective

Facial nerve palsy can be a sight-threatening complication. We have developed a flow diagram to aid in the management of these patients so that corneal complications may be avoided. This involves the recognition of a facial palsy and institution of treatment as guided by the flow chart.

Fifty-six patients suffered a facial nerve palsy following acoustic neuroma surgery. All received regular topical ocular lubrication, followed by either botulinum toxin A (BTXA)-induced ptosis (if corneal exposure developed despite conservative treatment) or definitive eyelid surgery.

Twenty-one patients required regular lubrication only. Of these patients treated for corneal exposure, 20 received BTXA with good resulting corneal cover. Unfortunately, 9 of these suffered diplopia, although in 4 this resolved quickly. Twenty-four patients underwent a total of 64 eyelid procedures including levator recession, lateral tarsorraphy, lateral canthal sling, medical canthoplasty and gold weight insertion. All patients had good corneal cover post-operatively and were cosmetically improved. Of the 56 patients with a facial nerve palsy, 7 presented with a corneal epithelial defect or an infected corneal ulcer. These all responded to treatment with BTXA, topical antibiotics and/or lubrication, and eyelid surgery.

Post-operative facial palsy may result in a significant ophthalmic workload. Although a proportion of patients with a facial nerve palsy manage well with regular lubrication, additional help with eyelid closure, either in the way of BTXA-induced ptosis in the short term or definitive eyelid surgery in the long term, is often required. Eyelid surgery seems to be the mainstay of treatment, for both function and cosmesis, with many patients requiring a combination of procedures.