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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 29-33

Dacron mesh encasement of gold weight implants in paralytic lagophthalmos


1 Eye Clinic, Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey
2 Eye Clinic, Kocaeli Körfez State Hospital, Kocaeli, Turkey

Date of Submission21-Jun-2015
Date of Acceptance28-Sep-2016
Date of Web Publication6-Dec-2016

Correspondence Address:
Işıl Kutlutürk
Anafartalar Caddesi, Cevizli Mahallesi, Taçmahal Sts, C Blok No: 11, Kartal, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.195306

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  Abstract 

Purpose: The purpose of this study is to evaluate the efficacy of Dacron mesh used as an encasement material for gold weight implantation, which is a new therapeutic technique, in patients with paralytic lagophthalmos. Materials and Methods: Fifteen eyelids of 14 patients with paralytic lagophthalmos, who underwent surgery with Dacron mesh-covered gold implants, were retrospectively reviewed. None of the patients had any eyelid surgery, and none had orbital or any other eyelid disease. All patients had various degrees of preoperative corneal pathology due to lagophthalmos. The patients were followed up for a mean of 17.5 ± 12.4 months (range: 6-36 months), and both postoperative success and complications were reported. Pre- and post-operative lagophthalmos degrees were compared between cases with successful results and cases with complications. Preoperative lagophthalmos degrees of <9 mm versus ≥9 mm were also compared between successful and complicated cases. The Wilcoxon signed test was used to measure mean differences between pre- and post-operative values. Differences were statistically significant when P < 0.05. Results: During final visits, while 13 of 15 operated eyelids had adequate lid closure with no complications, 3 of 15 patients developed inflammation and infection in the early postoperative period. During follow-up, two of complicated patients responded to treatment poorly, and implants were removed. Skin ulceration was observed in the third patient, and the implant was replaced with a new one with no Dacron coverage, achieving adequate lid closure and satisfaction. Conclusions: Dacron mesh may be a good option as a barrier for gold weight implants to prevent implant extrusions; however, the high rate of early postoperative inflammation raises concerns about its use.

Keywords: Dacron mesh, encasement materials, gold weight, lagophthalmos


How to cite this article:
Yazicioglu T, Kutlutürk I. Dacron mesh encasement of gold weight implants in paralytic lagophthalmos. J Clin Ophthalmol Res 2017;5:29-33

How to cite this URL:
Yazicioglu T, Kutlutürk I. Dacron mesh encasement of gold weight implants in paralytic lagophthalmos. J Clin Ophthalmol Res [serial online] 2017 [cited 2022 Jun 27];5:29-33. Available from: https://www.jcor.in/text.asp?2017/5/1/29/195306

Paralytic lagophthalmos is defined as the clinical picture characterized by incomplete closure of eyelids resulting from inadequate resistance against the elevating force of the levator muscle due to a failure in the neural stimulation of the orbicularis muscle. Inadequate closure of the eyelids leads to corneal abrasion, keratitis, infection, and corneal vascularization, which begin with impairment in the lacrimal film layer, and in advanced cases may lead to endophthalmitis, which may result in corneal ulceration, perforation, and loss of vision, although taping the eyelids shut at night and using night gels and artificial tears in daytime can provide symptomatic relief, surgical intervention is usually necessary to prevent existing complications. Among available surgical interventions are lateral and medial tarsorrhaphy, temporal and masseter muscle flaps, eyelid encirclage with a silicone yarn to facilitate eye occlusion, a metal spring to close palpebral fissures, and botulinum toxin injections to the levator muscle. [1],[2],[3],[4],[5] Although these methods are currently used, they are not preferred and are rarely performed due to restrictions in the peripheral visual field, inadequate corneal protection, anatomical impairment in the palpebral fissure, impairment in the spontaneous blink reflex, difficulties in balancing the yarn tension, the extrusion of the implant, and granuloma formation. [1],[2],[3],[4] In addition to all these surgical methods, the use of gold weight implants, consistently popular as a dynamic method, was first described in 1950 by Sheehan [5] and was first used in 1958 by Illig [6] in lagophthalmos cases. In subsequent years, gold weight implantation has been used by a number of surgeons and favorable outcomes have been reported. [5],[6],[7],[8],[9] However, contrary to these favorable outcomes, unintended local complications associated with gold weight usage have also been reported. [10] Some autogenic or allogeneic encasement materials, such as temporoparietal fascia, fascia lata, levator aponeurosis, dermal fat graft, processed human pericardium, and porous alloplastic materials, have been used in the past to reduce these complications. [11],[12],[13],[14],[15],[16] However, complete success has not been achieved with these materials. Thinning the graft, donor site problems, and the risk of transferring prion infection has always been a concern for alloplastic nonsynthetic materials. [17],[18],[19],[20],[21],[22]

The present study aimed to evaluate the efficacy of Dacron mesh used as an encasement material for gold weight implantation performed for the treatment of patients with paralytic lagophthalmos.


  Materials and Methods Top


Fifteen eyelids of 14 patients with paralytic lagophthalmos, with different etiologies, who underwent surgical correction of lagophthalmos using Dacron mesh-covered gold weight implants between 2007 and 2013, were included in the study [Table 1]. One patient with intracranial neoplasia had bilateral lagophthalmos and was treated bilaterally. No patients had any previous history of other eyelid/orbital disease or surgery, and biomicroscopy revealed various degrees of corneal involvement (keratopathy, infection, and vascularization) in all patients at their initial visit. Facial paralysis ranged between Grade 4 and 6 according to the House-Brackmann scale. All patients had given written informed consent in accordance with the Declaration of Helsinki. The Institutional Review Board of Kartal Training and Research Hospital approved the study. Of the study patients, nine were female, and five were male. The preoperative and postoperative degrees of lagophthalmos (distance between the eyelid margins with gentle closure) were measured by a surgical ruler, from where the distance between the margins of the eyelids was the maximum, and photographic recording was performed. Lower eyelid laxity and the presence of ectropion were assessed. The ideal implant weight was determined before surgery by placing the appropriate weight that provided adequate closure and without causing ptosis more than 2 mm, in a way accommodating the shape and curve of the upper eyelid, while the patient was in sitting position. Median ideal gold weight was 1.3 grams (range: 1.1-1.9 g).
Table 1: Etiologies, results, and complications

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Just before the surgical procedure, the determined appropriate gold weight was covered to full thickness by a single-layer Dacron (DuPont, Wilmington, DE, USA) polyester mesh. The mesh was then stabilized using 5.0 prolene suture [Figure 1]. Local anesthesia was performed in the upper eyelid with 1% lidocaine and 1:80000 adrenaline (about 1 ml). An incision was made on the supratarsal skin fold and after passing the orbicularis muscle, the tarsus was precisely exposed by elevating a suborbicularis flap inferiorly. The gold weight was placed in the sulcus created between tarsus and orbicularis muscle as inferiorly as possible in the mid-pupillary line. Attachment of the weight to the tarsus was provided using a 6.0 polypropylene suture passed through the three holes on the implant. The orbicularis muscle and the skin were sutured in layers with 6.0-coated Vicryl. Postoperative antibiotic (amoxicillin/clavulanic acid 875 mg/125 mg, once a day), and anti-inflammatory (paracetamol 500 mg, twice a day) treatment was performed on all patients.
Figure 1: The determined appropriate gold weight was covered as full-thickness by a single-layer Dacron (DuPont, Wilmington, DE, USA) polyester mesh. The determined appropriate gold weight was covered as full-thickness by a single-layer Dacron (DuPont, Wilmington, DE, USA) polyester mesh

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Postoperative follow-up of all the patients was performed weekly in the 1 st month and later monthly. Implant migration and extrusion, visibility of the gold implant trough the thin eyelid skin, postoperative ptosis, infection, long-term edema, and color changes were considered as complications. A decrease in lagophthalmos grade, a decrease in or the disappearance of preoperatively detected existing corneal abrasion and punctate keratopathy, an increase in visual acuity, and patient satisfaction concerning the decrease in sensations of dryness, grittiness, burning, foreign bodies, and stringy discharge and blurring of vision were considered as target surgical outcomes. Pre- and post-operative lagophthalmos degrees were compared between cases having a successful result and cases with complications. Preoperative lagophthalmos degrees of <9 mm versus ≥9 mm were also compared between successful and complicated cases. Statistical analysis was performed using SPSS 21.0 for Windows (SPSS Inc., Chicago, IL, USA). The normality of the distribution of the study sample was assessed by the Shapiro-Wilk test. The Wilcoxon Signed test was used to measure mean differences between pre- and post-operative values. Differences were statistically significant when P < 0.05.


  Results Top


The etiologies for each patient are given in [Table 1]. All patients had a certain type of lagophthalmos, and one of the cases had bilateral eyelid involvement. The mean age was 52.6 ± 13 years (range: 27-70 years) in females and 50.3 ± 10 years (range: 37-62 years) in males. Except for the existing etiology of paralysis, the patients had no diabetes mellitus, hypertension, or any other systemic diseases. The mean follow-up period was 17.5 ± 12.4 months (range: 6-36 months) [Table 1]. The mean preoperative lagophthalmos degree was 7.73 ± 2.4 mm, whereas the mean postoperative degree of lagophthalmos during the last visit of each patient was 1.33 ± 2.4 mm. The mean preoperative lagophthalmos degree was significantly higher than of the mean postoperative lagophthalmos degree (P < 0.001). The mean preoperative visual acuity was 0.52 ± 0.32, whereas the mean postoperative visual acuity was 0.61 ± 0.32 (P = 0.298). Twelve of the 15 cases had no postoperative extrusion, migration, ptosis, visibility of the implants, reduced visual acuity, local edema, or color changes. During follow-up, three of the patients developed local complications. Two developed local inflammation and infection that poorly responded to treatment with antibiotic and anti-inflammatory therapy for 2 weeks; the implant was removed in the 4 th week after surgery. The patients refused reoperation, and new implants were not given in these cases. Skin ulceration was observed in the third patient. The implant was removed, and surgery was repeated 3 months later. The patient had adequate lid closure at the final follow-up. In addition, three patients underwent ectropion surgery due to an increased laxity of the lower eyelid during follow-up [Figure 2]. Pre- and post-operative lagophthalmos degrees were significantly high in the complicated cases group (P = 0.013 and P = 0.001 respectively). Preoperative lagophthalmos degrees (≥9 mm) were significantly higher in the complicated cases group (P = 0.022). Patient satisfaction and an adequate lid closure (<3 mm) were achieved in 13 cases at the final follow-up, except for the two cases that required implant removal. It was observed that central keratopathy and corneal abrasion disappeared in all patients, and existing central keratopathy reached the lower quadrant in three patients.
Figure 2: (a and b) Pre-and post-operative photographs of a patient having lower eyelid ectropion surgery

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  Discussion Top


The use of gold weight implants has been preferred to other materials particularly for its inertness, high density, malleability, and nonallergic properties and its good color camouflage. Some local complications associated with this technique have been reported along with its widespread use in correcting lagophthalmos. [7],[8],[9],[10],[17] These complications include extrusion (3%-7%), migration (8%-10%), visibility through the skin, wound infection (7%-10%), ptosis (15%-25%), and residual lagophthalmos (8%-15%); the main cause of the first three complications is orbicularis muscle erosion due to friction between the gold implant and orbicularis muscle. Some measures were taken to prevent these complications, including suture fixation of the implant to the tarsus and changing the design of the implant to an elliptical configuration. [18],[19] However, despite these two new practices, extrusion and migration have continued to be encountered (rates: 0.5% and 0.4%, respectively).

Waysong P. reported De Angelis et al. describing three patients who underwent implant replacement with Dacron mesh. They believed Dacron mesh to be inert and porous, and thus would allow tissue in-growth and greater stabilization. The follow-up time was at least 2 years. The first patient had a sudden implant extrusion, while the second had edema and erythema, with no infection signs, at 3 months. The third patient's implant was stabile. They suggested that studies with larger series be conducted to find out whether the delayed inflammatory reaction and erosion were common and whether they could be prevented. [23],[24]

Considering that the main problem for all the barrier materials is the need for a cost-effective material that maintains barrier function for a long time and does not cause donor-site morbidity, we preferred to use Dacron mesh in the present study. Benefiting from being a nonabsorbable and porous structure, Dacron mesh can easily penetrate the healing tissue; from the foreign-body reaction induced, we targeted creating a strong barrier function by reducing friction between the implant and orbicularis muscle. During follow-up, implant stability and position were excellent in 12 of 15 eyes, with no persistent edema, ptosis, color changes of the skin, and most importantly, visibility through the skin. Postoperative inflammation and infection that poorly responded to treatment developed in 3 of 15 operated eyelids. The reasons were thought to be an early severe foreign-body reaction and a secondary infection. Two of these patients had relief after removal of the implant; however, lagophthalmos was still a problem since no new implants were inserted. Skin ulceration followed the early postoperative inflammation, and the patient underwent revision surgery, which provided a satisfactory outcome with the new implant. In all these cases, the preoperative degree of lagophthalmos was higher than 9 mm, and the comparison of cases with higher lagophthalmos (<9 mm vs. ≥9 mm) revealed a significant difference (P = 0.022). We hypothesized that the larger implant size to address the higher degree of lagophthalmos and the relative inadequacy of the pretarsal area might be the reason for the skin ulceration and the implant replacement being performed. The amount of skin ulceration was consistent with those reported in the literature, but the local infection was higher than reported by Pereira and Glória and Yu et al. [10],[25]


  Conclusions Top


We believe Dacron mesh can be considered as a good barrier material in the treatment of lagophthalmos to encase the gold implant, as a result of 13 of 15 successfully operated eye rate in this study; however, there is a risk of foreign-body reaction response in the early postoperative phase in patients with preoperative lagophthalmos higher than 9 mm. This study is also the first published assessment of Dacron mesh usage as an encasement material in lagophthalmos surgery. As such, favorable implant size, conformation, and local implant complications with new surgery outcomes should be evaluated in future studies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

  • Category 1: substantial contributions to conception and design, acquisition of data or analysis and interpretation of data (T.Y., I.K.)
  • Category 2: drafting the article or revising it critically for important intellectual content (T.Y., I.K.)
  • Category 3: final approval of the version to be published (T.Y., I.K.).


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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