Facial palsy or paralysis of the face has a range of effects. Radhika Holmström investigates.
Some eye conditions are the result of damage to the mechanics of the eye. Others are caused by malfunctions in the way that the brain processes the information carried to it from the eye.Then there are the eye conditions that happen when the structures around the eye are damaged, affect the eye's ability to control its movements and or compromising its health in other ways. Facial nerve palsy falls into this last group.
What is facial palsy?
The term is a description rather than an actual condition in its own right, because facial palsy - or paralysis of the face - can be caused by a lot of different conditions. The most common one is Bell's palsy, which is thought to be caused by a viral infection - which has affected George Clooney among others. Surgery to remove a tumour in the face can bruise the facial nerves and some congenital or genetic conditions produce facial palsy as well.
Sometimes the injury recovers within a few weeks, if the nerve has only been lightly damaged. If the damage is more severe, but the nerve retains its outer layer, it will start to recover slowly - usually taking around four months before the first improvements become apparent. A "third degree" injury, though, takes a very long time to recover - if at all (if the nerve has been completely severed, it will need to be repaired surgically) and it is very unlikely to recover completely.
The effects
Different parts of the face can be affected, too, depending on which side and which area has been damaged. The face has two main nerves, each starting in the brain and entering the face at the front of the ear to divide into five separate branches which supply the muscles, tears, saliva production and taste for that side. The paralysis can be just on one side of the face - or just one area, such as the lower half - on one or both sides.
All in all, though, the effects can be considerable. The muscles and nerves in the face are responsible for a huge number of functions, from raising the eyebrows to wrinkling the nose to smiling; and, significantly, to controlling the circle of muscle around the eye. So while some of the problems that facial palsy causes are cosmetic, because it leaves the person with a face that does not move, and looks 'odd' - and this in itself can have a significant psychological impact - it can also, at its most severe, be quite disabling.
Facial palsy's effects on the eyes
When it comes to the eye specifically, the upper eyelid may not close fully, there may be problems with blinking, and or the lower eyelid may droop down and flop away from the eye. The eye can become sore, red and dry because tears are not spreading over the eye (and this can affect the sight); or, conversely, the eye may water because the lower eyelid is not moving tears towards the tear drainage ducts at the corner.
At its worst it can lead to blindness - but that is very rare. "Traditionally, facial palsy doesn't fall into one of those areas that cause visual loss," explains Ahmed Sadiq, consultant ophthalmic and oculoplastic surgeon at Manchester Royal Eye Hospital.
"It's a very small proportion of people who lose their sight from their eye drying out. The drying in itself isn't too damaging; regular lubrication is essential, though, because if they don't, and their eye gets scratched as a result, that does damage the sight."
Sadiq's patients fall into that tiny minority, however - which is one reason why he is on the medical advisory board of the new charity Facial Palsy UK - often because they have other very serious conditions such as tumours on the nerves, and or have had nerve damage after surgery.
Treatments
"Our first concern is always about protecting the cornea," says Ruth Manners, consultant ophthalmologist and ocular plastic surgeon at University Hospital Southampton. "If this dries out, it gets desiccated, ulcerated and eventually gets scarred. Initially, this involves lubrication with drops and ointments, and possibly taping the lids closed at night - people get quite adept at this, just using ordinary tape. There's also a range of procedures and techniques that can help it close, like stick-on weights or botulinum injections to the upper lids."
That may not be enough, however. "If the damage is quite extensive, and especially if they are very uncomfortable, we'll do an operation to repair it," says Sadiq. "That's my main focus, though bear in mind I do have a work with a particular population, and the average eye surgeon might well only operate on a patient with facial palsy once every couple of years. The main aim, when we operate, is to reduce the exposed surface of the eye. We'll aim for the lid that is causing the most problem, and either push it up (if it's the lower one) or lower it (if it's the upper one)."
Surgery
Surgery may be temporary or permanent. One option that has been quite widely adopted is 'eyelid weighting', stitching in a small weight to help the upper eyelid more fully. However, this does not work for everyone. Raman Malhotra, who is a consultant ophthalmologist and oculoplastic surgeon at Queen Victoria Hospital in East Grinstead, explains: "The traditional method involves a gold weight in the shape of a rectangle inserted into the eyelid crease. These often show up, as a lump on the eyelid - and they can cause complications too. The corners can poke through the skin."
There is also the risk of rejection. Platinum is less easily rejected, but it is extremely expensive and there is still the potential problem of poking through. Malhotra and his colleagues are working on an affordable platinum alternative.
"We have successfully designed and are trialling a system where a surgeon stitches in the individual links of a chain. That is a lot less expensive and it's also uniquely adapted to the person's own shape - and it's also much easier to adjust the weight because we can remove or add individual segments."
Working together
The other point that specialists flag up is that this is very much a multi-disciplinary area. Manners points to the new Wessex Facial Nerve Centre, which brings together all the different professionals involved in the condition. "There is a whole range of surgery that plastic surgeons do on the lower part of the face, and we'll often have to coordinate with them too, especially if it's about dragging and drooping in that half of the face," she explains.
Sadiq stresses, too, that the 'cosmetic' aspects can have a quite profound psychological impact. "The rates of depression double in people with facial palsy," he says. So while the condition may not affect the sight permanently in many people, it's far from a minor issue.
More information
Read about Karen Johnson's experience of facial palsy.
Article originally published in NB magazine March 2013.