Management of a case of lagophthalmos by Gillies' method (a case report).

R Mukherjee, S Dasgupta, DS Ladi, VH Gandhi 
 Department of Ophthalmology, Dr R. N. Cooper Hospital, Bombay, Maharashtra.

Correspondence Address:
R Mukherjee
Department of Ophthalmology, Dr R. N. Cooper Hospital, Bombay, Maharashtra.

Full Text

::   Introduction

A patient with facial palsy is an unhappy individual with distressing ocular problems like lagophthalmos and exposure keratitis apart from the cosmetic disfigurement. Gillies[1] has described the method of temporalis transfer for surgical correction of lagophthalmos, while Thagarajs has described a modification of the above procedure. Other authors have not had a good success rate with the above procedures[2].

We describe a variation in the original Gillies’ method with good results in one patient.

::   Case report

A 45-year-old female patient presented with a history of inability to close the right eye since 6 months of age and with watering, redness and foreign body sensation since few months.

On examination, the patient had a right infranuclear facial palsy with palpebral aperture width of 7 mm. Despite a good Bell's phenomenon, exposure keratitis was present in the lower half of the cornea. (See [Figure:1]) Lateral tarsorrhaphy done twice, improved the exposure keratitis. Eventually, surgery was performed due to a cosmetic blemish.

Under local infiltration anaesthesia, an incision was made over the temporalis muscle in the temporal fossa. The temporalis fascia was dissected off in a vertical strip of 8 mm width, which was hinged superiorly. The hinge was established with nonabsorbable sutures of 6-0 nylon at the apex strengthening the fascia periosteum junction. A block of muscle wider than the fascial strip was dissected downwards towards the zygomatic arch. The band of temporalis fascia was divided into two halves of 4 mm each forming a Y-shaped band.

Tunnels were fashioned in the upper and lower lids near the margins from the lateral to the medial canthus between the tarsal plate and the orbicularis. The fascial strips were threaded through the tunnels and secured to the medial canthal ligament to leave 1 cm gap between the lid margins.

At the end of 1 week post-operatively, lagophthalmos still persisted. The medial incision was opened and the upper fascial strip was retightened so that the upper lid margin overlapped the lower.

The patient was followed up on a weekly basis and gradually phased out. Chewing exercises were given to strengthen the temporalis muscle.

For the initial 6 weeks, lagophthalmos was at a minimum with almost total corneal coverage. The patient was irregular in following up later.

When the patient was seen 6 months later, the lagophthalmos had imporved considerably with only 3 mm exposure on lid closure. Forcible clenching of teeth resulted in total lid closure. Exposure keratitis had disappeared. Lid contours were normal and only a mild bulge was present temporally. (See [Figure:2] and [Figure:3]).

::   Discussion

The surgical methods for correction of lagophthalmos described are: 1) Lateral tarsorrhaphy, 2) lid loading procedures, 3) Morel-Fatio spring[4], 4) silicon sling, 5) lid magnets, 6) temporalis transfer and its modification[1],[3],[5], 7) free muscle grafts[6], 8) cross facial nerve transfer and 9) temporalis reinnervation with sural nerve grafts. Gillies'[1] and Thagaraj's[5] methods were reported to give good and long lasting results in cases of lagophthalmos due to leprosy. However, after an initial & improvement, the long-term function was found to diminish. Hence, they were recommended only after other procedures failed.

In our patient, in the initial procedure the slings were tied with a lower tension leaving 1 cm gap in the palpebral apperture in accordance with Gillies' description. The lagophthalmos continued to persist. After the secondary retightening the procedure causing a lid overlap, lagophthalmos improved and was maintained beyond 1 year post-operatively, in contrast with above results, we attribute this improvement of function to the increased tension applied while tightening the sling and advocate this step as a primary procedure during the Gillies' operation.

::   Acknowledgment

We are grateful to the Medical Superintendent, Dr RN Cooper Hospital, for allowing us to publish this case.

References