Patients’ perspectives of ophthalmic management of facial nerve paralysis

Abstract

Objective

Facial nerve paralysis (FNP) affects eye muscle function causing lagophthalmos. This leaves the cornea vulnerable to irritation and injury which, if untreated, may cause permanent vision impairment. Decreased eye muscle control impacts facial expressions and quality of life. Although non-surgical interventions such as lubrication are routinely used in standard eyecare, patient perspectives regarding these interventions have not been extensively investigated. This study aims to investigate patients’ perspectives of conservative ophthalmic management for FNP.

Methods and analysis

Participants with FNP completed a survey including seven conservative lagophthalmos management interventions: artificial tears, lubricating ointment, taping the eye shut, tape to lift the lower eyelid, scleral contact lens, moisture chamber and manual eye closure. Open-ended questions and Likert scales covered six domains: discomfort, appearance-related concerns, application difficulties, impact on activities of daily living and social activities, and tolerance to outdoor settings. Descriptive, bivariate, correlation and thematic analyses were undertaken.

Results

49 participants completed the survey (17 males, 32 females; mean age 55 years, SD 14.94). Mean duration of FNP was 8 years, 5 months (range 12 months to 47 years). Artificial tears and lubricating ointments were most frequently used with highest overall satisfaction. Participants were less satisfied with interventions involving the use of tape. Manual eye closure had a small positive impact. Main themes were comfort, vision and appearance.

Conclusions

Functional, social and psychological impairments associated with lagophthalmos are managed using conservative interventions. A better understanding of a patient’s capacity, priorities and preferences underpins a collaborative approach when selecting eye-protective interventions and optimises patient outcomes.

The main limitation of this study was that participants were recruited from a specialty facial nerve clinic, resulting in an over-representation of individuals with long-standing, complex conditions.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Lagophthalmos is a serious consequence of facial nerve paralysis and requires a multidisciplinary approach to maximise outcomes. Both conservative and surgical approaches are used with variable results which are mainly reported in terms of ocular condition.

WHAT THIS STUDY ADDS

• This study explores patients’ perspectives and experiences of conservative eye care following facial nerve paralysis. It provides information about satisfaction and degree of difficulty when applying commonly used interventions including eye-drops, lubricating gel and taping the eye shut.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study informs clinicians about the need for authentic communication with patients about the positive and negative impacts of a broad range of issues related to conservative eye protections for lagophthalmos following facial nerve paralysis.

Introduction

Ophthalmic complications following facial nerve paralysis (FNP) from Bell’s palsy, tumours, trauma and herpes zoster oticus/Ramsay Hunt syndrome include lagophthalmos which may result in exposure keratopathy, corneal ulcers or scarring.¹ Patients report reduced quality of life,² with eye complications both socially and functionally debilitating,³ requiring eye protection.⁴ FNP disrupts the innervation of orbicularis oculi, leaving levator palpebrae to act unopposed, affecting volitional eye closure and blinking.⁵ This causes retraction and suboptimal function of the upper and lower eyelids,⁶ including paralytic ectropion.⁷

Management of FNP and lagophthalmos requires a multidisciplinary approach including conservative and surgical interventions.⁸ Conservative interventions include moisture chambers, silicon-hydrogel contact lenses, preservative-free drops and gel, manual eyelid stretching and eyelid taping.59,11 To lift the lower eyelid, a strip of adhesive tape may be applied from the centre of the lower eyelid with a superior-lateral pull to the lateral orbital rim aiming for lower eyelid elevation. This improves lagophthalmos by reducing the aperture of the palpebral fissure to assist with effective eye closure and improves lacrimation by restoring the lower eyelid position to bring the reservoir of tears back into contact with the cornea.⁹ Furthermore, botulinum toxin type A injections may be used to weaken levator palpebrae, inducing temporary upper eyelid ptosis for corneal protection.⁶ Despite these measures, eye discomfort occurs during showering or swimming, and windy, dry and dusty conditions.¹²

Lagophthalmos surgery may involve upper and lower eyelids separately or together.⁶ Surgical tarsorrhaphy involves suturing a portion of the upper and lower eyelid together, to shorten the palpebral aperture, reducing ocular surface exposure.¹¹ Outcomes are variable⁸ and may have poor cosmetic outcomes if reversed.⁶

Upper lid loading improves quality of life via the implantation of a gold or platinum weight or platinum chain into the upper eyelid, increasing the effect of gravity on the upper lid and facilitating passive eyelid closure.^{6 8 13 14} Disadvantages include expensive cost, local inflammation, incomplete eye closure in supine and possibility of extrusion.¹⁵ Lower eyelid tightening procedures include medial canthal tendon plication, medial and lateral tarsal strips; however, they can irreversibly shorten the lower eyelid, thereby sometimes requiring lower eyelid lengthening procedures.¹⁶

Despite frequently being used, there is little research regarding patients’ preferences and quality of life impacts of conservative interventions to manage lagophthalmos following FNP. Patient-appropriate, tailored eye protection is the accepted standard of mode of care, as comparative studies with a no-treatment arm are unethical.¹⁷ Therefore, this study aims to investigate patients’ perspectives by exploring their preferences and experiences of conservative eye protections for lagophthalmos.

Methods

A self-administered survey was conducted using REDCap. A convenience sample of participants was surveyed from the Sydney Facial Nerve Clinic between 27 July and 26 September 2020. Eligibility criteria included participants over 18 years old with unilateral FNP, who had been treated for an eye-related condition associated with FNP. Survey responses were deidentified. Public and patients were not involved with the design, conduct, dissemination of results or evaluation of this study.

There were 187 survey fields with 14 demographic questions including gender, age, cause and duration of FNP, and eye-related medical and surgical history. Seven sections related to conservative lagophthalmos interventions: artificial tears, lubricating ointment, taping the eye shut, tape to lift the lower eyelid, scleral contact lens, moisture chamber and manual eye closure. For each intervention, there were 22 questions involving Likert scale responses and short answers. Questions covered overall satisfaction, duration of use, application difficulty, if assistance was required, and patients’ perceptions of the impact of the interventions: comfort, appearance-related concerns, activities of daily living (ADL), willingness to engage with others socially, tolerance to outdoor settings. The domains were based on common eye-related issues reported to facial nerve clinicians.

Participants rated application difficulty: 0=no difficulty; 100=extreme difficulty. For the amount of assistance provided: 0=no assistance, 100=fully assisted. Participant perception of a positive or negative impact of the intervention rated: 0=extremely negative effect, 50=no effect and 100=extremely positive effect.

Descriptive statistics and bivariate correlation analyses were performed using SPSS V.26.0. Thematic analysis using a theoretical approach was performed on short answer responses using the method by Braun and Clarke.¹⁸ Key themes were identified, coded and matched with exemplar quotes. Qualitative and quantitative data were examined to gain understanding of patients’ perspectives about interventions.

Results

Demographics

49 participants completed the survey (17 males, 32 females; mean age 55 years, SD 14.94). Mean duration FNP: 8 years, 5 months (range 12 months to 47 years). Bell’s palsy most common cause of FNP, accidental trauma least common. Mean duration of FNP: 8 years 5 months. The longest duration of FNP was herpes zoster oticus/Ramsay Hunt syndrome. Accidental trauma, iatrogenic injury and Bell’s palsy had shorter durations of FNP. 26 participants had eye-related surgery including gold or platinum weights, lower eyelid sling, brow lift, tarsorrhaphy and canthoplasty. Participants with iatrogenic surgical trauma had most eye-related surgery (n=13) and herpes zoster oticus/Ramsay Hunt syndrome the least (n=1) (table 1).

Table 1. Participant aetiology and demographics.

Aetiology	n	Mean age in years (SD)	Gender male	Gender female	Mean duration of FNP in years (SD)	Use of eye protective mechanisms for more than 4 Weeks	Previous eye-related surgery
Bell’s palsy	19	52 (11.95)	4	15	8 (9.52)	14	5
Iatrogenic (surgical trauma)	13	59 (17.53)	7	6	8 (9.61)	12	13
Tumour (eg, facial nerve neuroma or malignancy of the facial nerve)	5	54 (20.71)	1	4	10 (8.68)	4	4
Herpes zoster oticus/Ramsay Hunt syndrome	5	63 (9.43)	2	3	13 (19.36)	4	1
Trauma—accidental (eg, skull base or facial fracture)	3	49 (14.47)	1	2	6 (2.62)	3	2
Unknown cause	4	52 (17.42)	2	2	8 (8.31)	3	1

FNP, facial nerve paralysis.

Conservative interventions

40 participants used conservative eye-protective interventions for more than 4 weeks, especially following Bell’s palsy (n=14) (table 1). Artificial tears were the most commonly used intervention by participants with all causes of FNP. Artificial tears, lubricating ointment and tape to shut the eye were used by participants of all aetiologies. Those with Bell’s palsy used tape to shut the eye more frequently than lubricating ointment, while those with iatrogenic surgical causes of FNP used lubricating ointment more frequently than tape to shut the eye. Participants with iatrogenic causes of FNP were the only subgroup to use all eye-protective interventions, and the only subgroup to use moisture chambers and scleral contact lenses (table 2).

Table 2. Intervention use by aetiology.

Aetiology	Artificial tears	Lubricating ointment	Tape to shut the eye	Manual eye closure	Tape to lift the lower eyelid	Moisture chamber	Scleral contact lens
Bell’s palsy	16	12	15	6	0	0	0
Iatrogenic (surgical trauma)	12	11	9	5	2	2	2
Tumour (eg, facial nerve neuroma or malignancy of the facial nerve)	5	5	3	0	0	0	0
Herpes zoster oticus/Ramsay Hunt syndrome	5	2	2	1	0	0	0
Trauma—accidental (eg, skull base or facial fracture)	3	2	2	1	0	0	0
Unknown cause	2	2	1	0	1	0	0

Artificial tears and lubricating ointment

The most commonly used interventions were artificial tears (n=43) and lubricating ointment (n=34), which apply lubrication directly to the cornea. These interventions were rated highest in terms of overall satisfaction, and there was a positive correlation between overall satisfaction with lubricating ointment and eye-related comfort (r=0.530, p=0.035). They were also used for the longest duration (>3 years). The degree of application difficulty for artificial tears was highly correlated with application assistance that was provided for this intervention (r=0.880, p=0.009), as was the case for lubricating ointment (r=0.670, p=0.034). Both interventions had positive impacts on comfort and tolerance to outdoor settings (table 3a,b). Participants frequently reported that these interventions provided relief from dry eyes, particularly when outdoors (table 4). However, both had a negative impact on appearance and willingness to socially engage with others as attention was drawn to their affected eye by making it look moist and shiny (table 4). For lubricating ointment, appearance-related concerns were negatively correlated with willingness to socially engage with others (r=0.950, p=0.050). Artificial tears had a positive impact on ADL, while lubricating ointment had a negative impact with both interventions causing blurred vision (table 3a,b; table 4).

Table 3. Mean ratings for interventions according to domains.

(a)
Interventions and (n used)	Duration of use in years (SD)	Application difficulty (SD)*	Application assistance required (SD)†	Impact: comfort (SD)‡	Impact: appearance (SD)‡	Impact: ADL (SD)‡	Impact: willingness to engage socially (SD)‡	Impact: tolerance to outdoor settings (SD)‡
Artificial tears (43)	3.47 (3.37)	66.0 (32.06)	64.09 (34.43)	74.03 (20.81)	46.44 (19.74)	59.77 (21.82)	40.40 (25.01)	57.35 (25.60)
Lubricating ointment (34)	3.97 (6.68)	71.92 (17.71)	93.91 (29.19)	67.17 (27.25)	39.78 (18.31)	46.25 (19.54)	37.33 (21.23)	57.29 (27.12)
Tape to shut the eye (32)	1.96 (5.50)	84.57 (9.86)	87.7 (11.53)	57.05 (29.34)	26.05 (22.95)	33.55 (28.94)	18.38 (14.38)	38.75 (32.11)
Manual eye closure (14)	2.13 (2.67)	73.0 (0.00)	0	80.67 (8.89)	30.0 (7.07)	25.67 (10.6)	21.67 (3.79)	52.0 (23.52)
Tape to lift the lower eyelid (3)	1.92 (2.68)	100.0 (0.0)	100.0 (0.0)	90.0 (0.0)	50.0 (0.0)	0	0	0
Moisture chamber (2)	0.58 (0.59)	0	100.0 (0.0)	84.0 (0.0)	10.0 (0.0)	63.0 (0.0)	0	74.0 (0.0)
Scleral contact lens (2)	0.54 (0.65)	65.0 (21.21)	100.0 (0.0)	79.0 (15.56)	0	90.0 (0.0)	0	67.0 (0.0)
Overall mean (SD) (2.08; 1.30)	76.75 (13.36)	87.62 (15.50)	75.99 (11.05)	33.71 (14.83)	54.03 (32.18)	29.45 (11.03)	26.45 (11.03)	57.73 (12.20)

(b)
Interventions	Impact: overall satisfaction (SD)§	Overall satisfaction – range§
Artificial tears	70.61 (20.62)	15–100
Lubricating ointment	68.0 (17.47)	35–100
Tape to shut the eye	50.96 (30.99)	0–100
Manual eye closure	58.26 (22.16)	25–100
Tape to lift the lower eyelid	35.78 (25.7)	0–70
Moisture chamber	42.5 (11.90)	30–55
Scleral contact lens	61.5 (19.12)	50–90
Overall mean (SD)	55.37 (25.01)	0–100

^*0=no difficulty, 100=esteem difficulty.

^†0=no assistance, 100=fully assisted.

^‡0=extremely negative effect, 50=no effect, 100=extremely positive effect.

^§0=extremely dissatisfied, 50=neither satisfied nor dissatisfied, 100=extremely satisfied.

ADL, activities of daily living.

Table 4. Thematic analysis of comments about comfort, vision and appearance of eye interventions.

Interventions	Comfort	Vision	Appearance
Artificial tears	Lubricate eye, reduced spiking feeling Provide relief from dryness and irritation, but often only bring relief	Made vision blurry due to watery eye Soothing during outdoor activities especially when windy of very sunny; also when bright lights indoors. Need for caution as can blur vision Unsure if Bell’s palsy or eyedrops, but sensitive to sunlight and teary eyes when eating	Made my eyes water and glassy Affects wearing eye makeup and highlights differences in eyes due to Bell’s palsy Eye-drops would make me feel self-conscious and unable to go out because of this
Lubricating ointment	Helps with dryness of my eye Affected the comfort of having something foreign in my eye	Eyesight very blurry for quite some time after application Affected my vision, I could not see properly from that eye. Affected my ability to read, work on computers, drive a car (especially at night) and cross the road (had to turn my head a lot further to see with my good eye) Eye can be blurry in the morning affecting my ability to drive to work	Eyes often appear greasy Shiny ointment drew attention to my bad eye I could look more normal and make eye contact while speaking and listening. I didn’t feel as self-conscious so could relax a bit more Paranoid that it drew attention to my bad eye
Tape to shut the eye	It allowed me to sleep without the worry of eye damage, plus allowed my eye to rest and recover, although eventually the tape caused rashes on my skin Helped keep the eye closed so it did not dry out too much Uncomfortable, especially after regular use Relief from irritation and restful feeling for eye When the tape loosened and the eye opened it was uncomfortable	Difficult to keep eye shut, challenging to function with only one sighted eye Difficult to drive, loss of balance Made driving challenging and anything that required depth perception	It was mainly used at night so only family saw me, however the red marks from the tape would last all day causing workmates to comment Very obvious sign that there was an issue with my eye Drew attention to my Bell’s palsy I did not socialise at all as too self-conscious I looked like a freak when eye taped shut and when wearing a patch I looked like an ugly pirate. I refused to go out in public The 6 months when eye needed to be taped increased social isolation, and wanting to avoid crowds and people other than family, close friends and work colleagues
Manual eye closure	I need to manually close my eye when it gets sore or irritated throughout the day Much more comfortable holding the lid closed Sometimes, my eye does not cope with being outside, so the quick and easy fix is to hold the eye closed, allowing me to stay out a bit longer		Sometimes I have to hold my eyelid closed at work, or out socialising, or out in public which sometimes caused comments Unusual to see someone walking around with finger holding eye closed At work, I have to stop working for 5 to 10 min in order to hold my eyelid closed, and sometimes I drive while holding my eyelid closed, especially on long journeys. While watching the end of a movie late at night I sometimes have to hold my eyelid shut whilst my good eye watches to the end Meetings at work, use of computer with one hand. Tiring for arm holding lid down for hours at a time

Taping to shut the eye

Tape used to shut the eye was the third most frequently used intervention (mean duration 1.96 years) with neutral overall satisfaction ratings (50.96). It was rated as highly difficult to apply (84.57) and often required assistance to apply (87.70) (table 3a,b) “I was unable to hold my eye shut properly and [apply the] tape at the same time”. It had a slightly positive impact on comfort (table 3a,b), “it helped to prevent the eye from drying”, but tape had poor adhesion and caused irritation and discomfort to the periocular region (table 4). Tape had a negative impact on appearance (26.05) “feeling self-conscious” and willingness to engage socially (18.38) leading to “social isolation” (table 3a,b; table 4). Of all interventions, tape had the second most negative impact on ADL (33.55). Monocular vision associated with the use of tape caused “difficulty with depth perception” and impacting “driving, sport [and] watching TV” (table 4).

Manual eye closure

Manual eye closure was used by 14 participants and had a slightly positive satisfaction rating (58.26). It was used for an average of 2.13 years. Manual eye closure had a positive impact on comfort (80.67), their eye “felt more comfortable”, which is the highest of the four most commonly used interventions (table 3a,b). In outdoor settings, it was “a quick and easy fix… allowing me to stay [outdoors] a bit longer” (table 4). Manual eye closure had a detrimental impact on appearance (30.00), ADL (25.67) and willingness to engage socially (21.67) (table 3). It was tiring, time-consuming, attracted unwanted attention and was disruptive when driving or using a computer (table 4).

Moisture chambers, scleral contact lens and tape to lift the lower eyelid

Tape to lift the lower eyelid (n=3), moisture chambers (n=2) and scleral contact lens (n=2) had a positive impact on eye-related comfort (table 3a,b), shortest usage duration (<2 years), but they were least used. Scleral contact lenses had positive satisfaction ratings; however, tape to lift the lower eyelid and moisture chambers were the only two interventions with negative overall satisfaction ratings. However, there is inadequate data for generalisable results regarding patient perspectives.

Discussion

This study explored patients’ perspectives of ophthalmic interventions used in the management of lagophthalmos associated with FNP. Participants in this study had similar facial nerve characteristics as samples from larger studies, in that the predominant aetiologies were Bell’s palsy and iatrogenic surgical injury, and most participants were female.^{19 20} In this study, the mean duration of FNP was 8 years, 4 months. Therefore, participants had significant experience living with FNP and managing lagophthalmos, with 80% using eye-protective interventions for 4 weeks or more. Therefore, participants’ perspectives and experiences provide valuable insight into factors that influence patients’ preferences for ophthalmic management of FNP.

Lubrication interventions

Highest overall satisfaction and positive impacts on comfort were reported for artificial tears and lubricating ointment, which were used most often and for the longest duration. This may be because they could be applied with greater ease and more independence than other interventions, allowing improved tolerance to outdoor settings, particularly windy environments. These results align with previous studies demonstrating that artificial tears improve eye-related comfort and provide symptomatic relief from dry eyes.^{21 22}

Negative impacts include blurred vision for both artificial tears and lubricating ointment. Previous studies reported that artificial tears maintained visual acuity while lubricating ointments are more likely to blur vision.^{17 23} Lubricating ointments had negative impacts on reading, computer work and driving and were rated as less comfortable than artificial tears. They have previously been associated with foreign body sensations.²³ In this study, participants who only used artificial tears reported light sensitivity, with suboptimal corneal hydration as a potential explanation, with artificial tears requiring more frequent administration than lubricating ointment.¹⁷

Another common issue for both interventions was a negative impact on appearance and willingness to socially engage with others. For artificial tears, patients reported excessive watering of the eye, and those who used lubricating ointment reported that their eyes appeared ‘shiny’ and ‘greasy’. Participants felt that both interventions drew attention to their affected eye, which caused them to feel self-conscious, a common feeling for people with facial difference.²⁴

To optimise patient outcomes and establish realistic expectations, clinicians should clearly explain the benefits related to eye comfort and improved tolerance to outdoor environments. This should be accompanied by discussions of potential negative consequences, such as changes in appearance, reduced visual acuity and increased difficulty with ADL. Practical suggestions including the use of wrap-around sunglasses may be recommended to decrease light sensitivity and address appearance-related concerns while supporting eye comfort.¹² Lubricating ointment may be preferred at night during sleep-time. Increasing patient understanding and integrating patient preferences may add time to clinical consultations; however, the overall beneficial effects on eyecare and realistic expectations are worthwhile.

Taping interventions

Tape to shut the eye was perceived as worst of all interventions in terms of comfort and had detrimental effects across all other domains (table 3a,b). Although participants reported that it provided relief from corneal irritation and dryness of the eye, as with other studies,25,27 it caused rashes, redness, skin irritation, pain on removal or discomfort when tape lost adhesion, causing the eye to open. When tape is used to completely shut the eye, binocular vision is lost, which may have a detrimental impact on motor task performance, including ability to navigate within the environment.^{28 29} When combined with negative impacts on appearance, this may increase social isolation. Significant stigma is associated with faces that do not fit with society’s perceived ideal appearance,²⁴ with those who do not conform often avoiding social encounters.³⁰ Despite limited data for lower eyelid taping, similar inferences may be made for tape to lift the lower eyelid, except for monocular vision.

Before considering taping, patients should be screened for allergy to skin adhesives and patch tested on a less vulnerable area to minimise skin irritation. Loss of adhesion may increase the risk of corneal exposure issues including abrasions.³¹ Questioning about available carer support to assist with application and supervised practice may optimise application techniques. Taping the eye shut during sleep may mitigate patients’ concerns about vision and appearance.^{6 8 12 32}

Manual eye closure

Manual eye closure, while improving comfort temporarily, is impractical as a standalone intervention due to its time-consuming nature and hindrance to performing bimanual activities. Touching the face may draw unwanted attention, hence compounding social stigma associated with facial difference.²⁴ Therefore, clinical discussions about appropriate scheduling of this complementary intervention may improve compliance.

Moisture chambers and scleral contact lenses

As these interventions were not commonly used, limited data were reported, making it difficult to make inferences.

Conclusions

The aims of management for lagophthalmos in FNP include protection of the cornea, preservation of vision, optimising eye-related comfort and achieving good aesthetic outcomes.⁸ Our study found that while conservative measures are part of a comprehensive approach to eyecare following FNP, the patients’ perspectives on comfort, vision and appearance were key factors influencing satisfaction with interventions. When selecting eye-protective interventions, effective clinician communication and authentic collaboration with the patient, taking into account the individual patient’s context, capacity, priorities and preferences, may increase the likelihood of treatment adherence. A holistic approach optimises clinically effective treatment outcomes and quality of life.

This study took a broad approach and did not distinguish between different brands of product used within each intervention. Individual products may have differing properties which could impact patients’ preference and perspectives of the intervention.

Data availability statement

Data are available on reasonable request.