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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