Post-external dacryocystorhinostomy lagophthalmos

Abstract

To describe lagophthalmos and eyelid closure abnormality after external dacryocystorhinostomy (DCR). A retrospective review of medical records and postoperative photographs of 79 patients who underwent external DCR for nasolacrimal duct obstruction and developed eyelid closure abnormality and lagophthalmos with or without exposure keratopathy was conducted. Collected data included age, sex, indication for surgery, laterality, length and type of incision, length of follow-up duration, presence of punctate epithelial keratopathy, and time for resolution of eyelid closure abnormalities. Twenty-seven patients with 28 external dacryocystorhinostomy had postoperative eyelid closure abnormalities. Male to female ratio was 1:6. The mean age was 40.1 years (range 9-80 years). All surgeries were performed through diagonal skin incision. Lagophthalmos involving the medial third of the palpebral fissure was noticed in 28.6 % of cases. All patients had hypometric blink mainly of the upper eyelid. One patient had punctate epithelial keratopathy. Resolution of lagophthalmos was noticed over a period of 1-5 weeks with an average of 3 weeks. None of the patients continued to have residual hypometric blink or punctate keratopathy at the last follow-up time. The mean follow-up period was 4.2 months (range 3-6 months). Eyelid closure abnormality and lagophthalmos after external DCR are underestimated problems. Spontaneous resolution is seen in all cases weeks to months after surgery.

Temporary Medial Upper Eyelid Lagophthalmos after External Dacryocystorhinostomy

“…The observation made in the present paper that 3 out of 10 consecutive patients (30%) showed lagophthalmos as a transitory complication after external DCR is in agreement with another recent study where this complication occurred with an incidence of 28.6 % [4], therefore suggesting that the three cases reported here did not simply occur by coincidence. It is conceivable that such complication can often be overlooked, as after a DCR, patients are usually not carefully examined with their eyes closed and no attention is necessarily given to the asymmetry of their blinking, especially when these patients do not complain about it.…”

“…It is not excluded that, in the three cases reported here, the trauma to the facial fibers of the buccal or zygomatic branches occurred during the orbicularis muscle disinsertion from the periosteum of the ascending process of maxilla or, during the osteotomy. However, orbicularis muscle disinsertion alone can not explain the present findings as in one of the two clinical studies depicting 28.6 % lagophthalmos after external DCR [4], the orbicularis muscle was not disinserted from the periosteum but the periosteum itself, with the attached orbicularis, was lifted off the ascending process of maxilla.…”

“…Temporary lagophthalmos can occur as a complication of external dacryocystorhinostomy, most likely due to damage of the (only recently described) superficial buccal and/or zygomatic branches of the facial nerve that run upward to cross over the medial ligament and innervate the medial part of the orbicularis oculi muscle. tinely performed for more than hundred years, there exist only two clinical studies mentioning lagophthalmos as a complication of external DCR even though, in these studies, this complication appeared to occur at a frequency as high as 7.4% [3] or 28.6 % [4]. The present paper supports the fact that lagophthalmos is a transitory complication that can be observed after external DCR and further emphasizes that it seems to primarily result from a paresis of the medial part of the orbicularis oculi muscle of the upper eyelid.…”

“…It is also somehow astonishing, that for a procedure that still remains the gold standard of lacrimal surgery one hundred years having been described, there exist only two case-reports [11,12] and two clinical studies [3,4] mentioning lagophthalmos as a complication after DCR, a complication that in addition is reported not to be rare. Therefore, there is a real need for additional studies to be conducted in order to further confirm the incidence as well as to refine the pathophysiological mechanism of this complication.…”

Lagophthalmos of the medial upper eyelid after Mohs surgery of the medial canthus

“…Transient lagophthalmos is a well-described complication after external dacryocystorhinostomy (DCR), an ophthalmologic procedure in which a cutaneous incision is placed in the same region as our patient's defect. 2 , 3 , 4 Post-DCR lagophthalmos is hypothesized to result from injury to variant orbicularis innervation via the “angular” branch of the facial nerve.…”