Multiple gold weight implants to treat lagophthalmos and improve contour

Abstract

Purpose

To report a novel approach for managing persistent lagophthalmos and eyelid contour abnormality after initial gold weight implantation.

Observations

Paralytic lagophthalmos is defective eyelid closure due to facial nerve damage. One common, effective treatment is lid loading with eyelid weights. By implanting a weight into the upper eyelid, gravity is used to help close the eyelid, decrease corneal exposure, and prevent further disease such as exposure keratopathy. This case details a patient with paralytic lagophthalmos post resection of a vestibular schwannoma. She underwent gold weight implantation but still experienced incomplete eyelid closure and altered eyelid contour. Instead of performing common revision procedures such as repositioning or replacing the weight, a second, smaller, gold weight was added in the same eyelid.

Conclusions and Importance

Placement of a second gold weight in the same eyelid may represent a simple alternative to revision and replacement of initial gold weight.

Highlights

• •Dual gold eyelid weights used for persistent lagophthalmos.
• •Second lateral weight improved closure with modest contour improvement.
• •Alternative to implant exchange in revision surgery.

1. Introduction

Lagophthalmos is incomplete eyelid closure, commonly due to either eyelid or facial nerve damage.¹ Eyelid aetiologies include floppy eyelid syndrome, prior eyelid surgeries, chemical or thermal burns, and structural damage to the various layers of the eyelid. The facial nerve can be impaired by blunt trauma, tumours, infections, or Bell's palsy, amongst other causes, leading to paralytic lagophthalmos.² Because lagophthalmos can lead to many complications, such as dry eye disease and exposure keratopathy due to the increased exposure of the cornea, management of lagophthalmos is crucial.¹ Depending on the underlying cause and the severity of symptoms, lagophthalmos can be treated with artificial tears eye drops, ointments, tape to close the eyelids at night, external eyelid weights, or surgical interventions. Specifically, one common surgery to treat paralytic lagophthalmos is lid loading which involves implanting a small weight made of gold or platinum into the upper eyelid, using gravity to close the eyelid.³ This operation is generally effective, with one study finding that 97% of gold implants decreased corneal exposure and improved patient symptoms.⁴

However, complications include extrusion of the weight, astigmatism, and allergic reaction. Furthermore, dissatisfaction can arise from unsatisfactory eyelid contour, prominent bulge of the implant, ptosis due to overweight, and lack of symptom improvement due to underweight.5, 6, 7 These complications may require further revision procedures to remove, replace, or reposition the implant. Alternatively, this case report describes the decision of a patient and care team to add a second gold weight rather than replace it.

2. Case

A 53-year-old female was diagnosed with a right vestibular schwannoma. It was resected but was complicated by right CN VI and VII palsies. The CN VI palsy led to esotropia worse in the right gaze, and the CN VII palsy led to paralytic lagophthalmos of the upper and lower eyelids of the right eye. Due to the paralytic lagophthalmos, she soon developed exposure keratopathy, superficial punctate keratitis, and corneal subepithelial haze on exam.

To treat this paralytic lagophthalmos and prevent further corneal disease she received a 0.8g gold implant in the medial right upper eyelid and a permanent lateral tarsorrhaphy. Eighteen months later, the 0.8g gold weight was replaced with a 1.2g gold weight in the medial right upper eyelid, and the tarsorrhaphy was opened. While this improved cosmesis, she was dissatisfied with the contour caused by the gold implant in the medial portion (Fig. 1A) and the lagophthalmos of her right eye was still unresolved (Fig. 1B). A repeat procedure was planned to address these issues. The initial discussion centred on repositioning the implant to improve contour or replacing it with a larger weight to better close the eyelid. However, ultimately, the decision was made to add a second weight to accomplish both these purposes. A 0.8g gold weight was placed at the superior tarsal border in the lateral right upper eyelid and secured to the anterior aspect of the levator muscle, allowing the weight to remain posterior, which enabled her to completely close her right eyelid with modest improvement in eyelid contour, satisfying the patient (Fig. 2A and B). The patient remained stable at 18-month follow-up with satisfactory eyelid closure and no reported long-term complications.

Fig. 1.

(A) After opening of the tarsorrhaphy and replacement of the 0.8g gold weight with a 1.2g gold weight. (B) Lagophthalmos before lateral gold weight implanted. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2.

(A) Subtle improvement in eyelid contour one month after 0.8g gold weight implanted in lateral right upper eyelid. (B) Resolved lagophthalmos one month after 0.8g gold weight implanted in lateral right upper eyelid. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

3. Discussion

This case demonstrates the potential indications and complications of not only a single gold weight implant, but also multiple gold weight implants. It began as a common case of paralytic lagophthalmos caused by a cerebellopontine angle tumour, treated with permanent lateral tarsorrhaphy and lid loading with a gold weight, followed by opening of the tarsorrhaphy and replacement with a heavier weight. However, the clinical picture became more complex when the lagophthalmos still did not fully resolve and the patient was dissatisfied with the cosmesis of her eyelid. Typically, a repeat procedure to replace or reposition the weight would be considered. However, in this patient, significant tarsal laxity raised concern that a single, heavier or repositioned weight may not adequately distribute force across the eyelid, potentially resulting in persistent segmental drooping. Therefore, placement of a second gold weight was pursued to more evenly distribute weight across the lid and address both functional and aesthetic concerns.

This case suggests the potential indications and benefits of multiple gold implants in a single eyelid. When there are unsatisfactory eyelid contour and closure, placing another implant can increase the total weight and balance out the weight in the eyelid, thus addressing both these issues in a single procedure. Although eyelid closure improved significantly, improvement in contour is more subtle and may be influenced by variable compensatory eyelid retraction during photography (Fig. 2A and B).

Nonetheless, a drawback of multiple implants is the risk of complications. The risk of astigmatism, allergic reaction, under and over correction likely remain similar to those of a single implant. The risk for dissatisfaction with the cosmesis of the eyelid also still exists, especially considering that multiple implants can cause a bulge. Other complications, particularly extrusion, will be increased with multiple implants since either weight can be displaced.

Multiple gold weights must be considered in light of alternative options, especially in cases of persistent lagophthalmos and contour asymmetry. Lid loading with a platinum chain is another effective treatment for paralytic lagophthalmos: compared to gold weights, platinum chains have been shown in small sample sizes to have lower rates of complications, such as implant migration, prominence in the eyelid, and altered eyelid contour, ultimately resulting in fewer revision procedures.8, 9, 10 Nonetheless, gold weights are still often used as the initial definite treatment for long-term paralytic lagophthalmos due to greater affordability and availability. In patients with persistent lagophthalmos and contour asymmetry after gold weight implantation, the addition of a second gold weight should be discussed as a potential solution prior to implant exchange or conversion to platinum chain.

Patient consent

Consent to publish this case was obtained from the patient.

Artificial intelligence statement

The authors declared that AI was not used in preparation of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Matthew Lin: Conceptualization, Writing – original draft. Michelle Ho: Writing – review & editing. Gary Joseph Lelli: Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.