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CLINICAL MANAGEMENT GUIDELINES
Facial palsy (Bell’s Palsy)
Aetiology
Predisposing factors
Symptoms
Signs
Differential diagnosis
Paralysis of facial nerve (VII cranial nerve)
This Clinical Management Guideline addresses Bell’s Palsy (idiopathic
lower motor neurone facial nerve dysfunction), which constitutes 72% of
all facial palsy:
• annual incidence 20-30 per 100,000, especially between 15 & 45
yrs
• unilateral
• M = F (except in pregnancy, see below)
• cause unknown, but sometimes associated with latent virus
infection (HSV type 1, HZ)
• fair prognosis without treatment
- complete paralysis: 61% recovery rate
- incomplete paralysis: 94% recovery rate
• most improvement occurs within three weeks
Other causes of paralysis of the facial nerve, which are not addressed in
this Clinical Management Guideline, include:
• infection, e.g. otitis media
• trauma, e.g. temporal bone fracture
• tumour compressing the facial nerve, e.g. acoustic neuroma
• sarcoidosis
• Guillain-Barré syndrome
• cerebrovascular accident (stroke)
Bell’s Palsy is more common 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, reduced vision
Watering of eye (epiphora)
Unilateral facial weakness including orbicularis oculi
• incomplete blink leads to corneal drying
• incomplete closure at night (lagophthalmos) causes prolonged
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)
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)
Facial Palsy (Bell’s Palsy)
Version 11, Page 1 of 3
Date of search 16.08.15; Date of revision 18.12.15; Date of publication 02.03.16; Date for review 15.08.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Facial palsy (Bell’s Palsy)
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Tape lids closed at night (and during day if corneal desiccation is
marked)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Sunglasses for photophobia and general protection
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Therapeutic contact lens (if unresponsive to frequent use of ocular
lubricants)
• silicone hydrogel should be considered as first choice (however,
scleral lens gives maximum protection)
NB therapeutic contact lens fitting is contraindicated in cases of
neurotrophic keratitis with loss of corneal sensation (cranial nerve V).
Such patents are at high risk of infection, which may be further increased
by contact lens wear
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Pharmacological
Tear supplements / lubricants by day, unmedicated ointment at night
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Management Category
New cases, and where there is loss of corneal sensation:
A2: first aid measures and emergency (same day) referral to GP or
ophthalmologist
Improved prognosis in moderate/severe cases of Bell’s palsy if treated
with systemic corticosteroids within 72 hours of onset
NB: corneal ulceration due to exposure is potentially sight threatening
and may justify emergency referral
Recovering and established cases:
B2: alleviation/palliation; no referral
If cannot be managed easily, then:
B1: prescription of drugs; routine referral
Possible management by Ophthalmologist
Urgent medical treatment for new cases:
• systemic steroid
Temporary tarsorrhaphy
Upper lid lowering with botulinum toxin injection of levator muscle
Surgery for permanently unrecovered cases:
• tarsorrhaphy (permanent)
• upper lid lowering (surgery, gold weight)
• surgical sling to raise lower lid
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Baugh R, Basura G, Ishii L, et al. Clinical practice guideline: Bell’s palsy.
Otolaryngol Head Neck Surg. 2013;149(3)(suppl):S1-S27
de Almeida JR, Guyatt GH, Sud S, Dorion J, Hill MD, Kolber MR, Lea J,
Reg SL, Somogyi BK, Westerberg BD, White C, Chen JM; Bell Palsy
Facial Palsy (Bell’s Palsy)
Version 11, Page 2 of 3
Date of search 16.08.15; Date of revision 18.12.15; Date of publication 02.03.16; Date for review 15.08.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Facial palsy (Bell’s Palsy)
Working Group, Canadian Society of Otolaryngology. Management of
Bell Palsy: clinical practice guideline. Head and Neck Surgery and
Canadian Neurological Sciences Federation. CMAJ. 2014;186(12):91722
LAY SUMMARY
Facial palsy results if the nerve supplying the muscles of the face, including the circular muscle
around the eye, stops functioning. There are many causes, but Bell’s Palsy is the commonest,
accounting for nearly three quarters of all cases. Usually this affects only one side of the face and
is temporary, lasting around three weeks, though recovery may not be complete. The cause is
unknown. People between the ages of 15 and 45 are most likely to be affected, but the condition
is commoner in those who are pregnant, have diabetes or are living with HIV infection.
Patients notice that the affected side of the face droops and does not move. The eye may not
close properly and as a result it can become red, uncomfortable and watery. The optometrist will
examine the eye for signs of drying and for loss of feeling, which sometimes occurs. New cases
will be referred as emergencies to the GP or the ophthalmologist, as recovery is improved if steroid
tablets are given within 72 hours of the onset of symptoms. Longer-standing cases are managed
by the optometrist and if necessary referred routinely to the ophthalmologist.
The optometrist will usually prescribe artificial tears to be used frequently during the day and
ointment at night. Taping the eyelids closed at night may help. Sunglasses will often relieve light
sensitivity and physically protect the eye. Sometimes a contact lens will be fitted to protect the
cornea.
Facial Palsy (Bell’s Palsy)
Version 11, Page 3 of 3
Date of search 16.08.15; Date of revision 18.12.15; Date of publication 02.03.16; Date for review 15.08.17
© College of Optometrists