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Version 5 (16.01.09)
Name:
CONDITION
Facial Palsy (including Bell’s Palsy)
Aetiology
Paralysis of facial nerve (VII cranial nerve)
- Bell’s Palsy constitutes 72% of all facial palsy:
- annual incidence 20 per 100,000, especially between
15 & 45 yrs
- M = F (except in pregnancy, see below)
- caused by latent virus infection (HSV type 1, HZ)
- fair prognosis without treatment (75% recover normal
function)
- most improvement occurs within three weeks
Bell’s Palsy is commoner in:
- pregnancy (annual incidence increases to 45 per 100,000)
- diabetes
- HIV
Distressing cosmetic change due to loss of muscle tone on one
side of face
Ocular exposure causes:
- redness, discomfort, pain, photophobia
Watering of eye (epiphora)
Unilateral facial weakness including orbicularis oculi
- incomplete blink leads to corneal drying
- incomplete closure at night (lagophthalmos) causes
corneal exposure
- loss of lacrimal pump mechanism produces pooling and
epiphora
Conjunctival hyperaemia, oedema, staining
Corneal desiccation ranges from mild superficial punctate
erosions to frank ulceration (usually inferior)
Corneal sensation may be reduced or lost
Predisposing
factors
Symptoms
Signs
COMMENTS
Version 5 (16.01.09)
Name:
CONDITION
Facial Palsy (including Bell’s Palsy)
Other causes of facial nerve palsy:
- as part of a stroke (cerebro-vascular accident with
hemiplegia)
- infection (e.g. otitis media, Lyme disease)
- trauma (e.g. cranial fracture, facial laceration)
- tumour (e.g. acoustic neuroma: damage to nerve by
tumour OR secondary to surgical trauma)
Ectropion or Entropion
Other causes of lagophthalmos
- orbital (thyroid eye disease – assess by
exophthalmometry)
- mechanical (cicatricial – look for lid scarring)
- physiological (patient’s partner to check for full lid closure
at night)
Management by Optometrist
Differential
diagnosis
Non-pharmacological
Pharmacological
Therapeutic lens (if unresponsive to frequent use of ocular
lubricants)
- silicone hydrogel should be considered as first choice
(however, scleral lens gives maximum protection)
- cases of neurotrophic keratitis with loss of corneal
sensation (cranial nerve V) are at high risk of infection,
which may be further increased by contact lens wear
Tape lids closed at night
Sunglasses for photophobia and general protection
Artificial tears by day, unmedicated ointment at night
COMMENTS
Version 5 (16.01.09)
Name:
CONDITION
Facial Palsy (including Bell’s Palsy)
Management
category
New cases, and where there is loss of corneal sensation:
A2: first aid measures and urgent referral
Improved prognosis in moderate/severe cases of Bell’s palsy if
treated with systemic corticosteroids within 72 hours of onset
Recovering and established cases:
B2: alleviation/palliation; no referral
If cannot be managed easily, then:
B1: prescription of drugs; routine referral
NB: corneal ulceration due to exposure is potentially sight
threatening
COMMENTS
Version 5 (16.01.09)
Name:
CONDITION
Facial Palsy (including Bell’s Palsy)
Possible management by Ophthalmologist
Urgent medical treatment for new cases:
- systemic steroid
- systemic anti-viral
Temporary tarsorrhaphy
Surgery for permanently unrecovered cases:
- tarsorrhaphy (permanent)
- upper lid lowering (surgery, gold weight)
- surgical sling to raise lower lid
Evidence base
Engström M, Berg T, Stjernquist-Desatnik A, Axelsson S,
Pitkäranta A, Hultcrantz M, Kanerva M, Hanner P, Jonsson L.
Prednisolone and valaciclovir in Bell's palsy: a randomised,
double-blind, placebo-controlled, multicentre trial. Lancet Neurol.
2008 Nov;7(11):993-1000.
Authors conclusion: Prednisolone shortened the time to
complete recovery in patients with Bell's palsy, whereas
valaciclovir did not affect facial recovery.
(Oxford Centre for Evidence-based Medicine Level of Evidence
= 1a)
For other interventions and In the absence of other evidence,
management based on Clinical Consensus
(Oxford Centre for Evidence-based Medicine Level of Evidence
= 5)
COMMENTS