Ocular Findings in Bell's Palsy

OCULAR FINDINGS IN BELL'S PALSY BARRY WEPMAN, MD, LCDR, MC, USNR NEWPORT, RHODE ISLAND and

JuLES L. BAUM, MD BOSTON Thirty-three patients with Bell's palsy underwent ophthalmic examination, including Schirmer testing, corneal sensitivity measurement, and electromyography. Sixteen patients returned for follow-up after one year. Sixty-one percent of the patients initially showed punctate fluorescein staining of the inferior cornea. Electromyographic studies demonstrate a high correlation between orbicularis function and the presence of corneal epithelial staining. Our results demonstrate a high frequency of minor corneal involvement in the acute phase of Bell's palsy. Healing of the epithelial defects follows improvement in orbicularis function.

BELL's palsy is a peripheral facial nerve paralysis of unknown etiology. In the acute phase, incomplete lid closure and, in a few cases, decreased lacrimation1 bring the patient to the ophthalmologist's attention. The potential complications of exposure keratitis and cor-

Submitted for publication Oct 24, 1978. From the Naval Regional Medical Center (Dr Wepman) and the Department of Ophthalmology, Tufts-New England Medical Center (Dr Baum). This project was supported in part by the Office of Human Development, Rehabilitation Services Administration, Grant #16-P-57856/1-01 and by Training Grant #5-R01-EY00054-05, National Eye Institute, Bethesda, MD. The opinions or assertions contained herein are those of the authors and are not to be construed as official or reflecting the view of the Navy Department or the Naval Service at large. Reprint requests to New England Medical Center, Department of Ophthalmology, 171 Harrison Avenue, Boston, MA 02111 (Dr Baum).

neal ulceration are well known. 2 Most patients with Bell's palsy recover complete, or nearly complete, function spontaneously, obviating the need for continued ophthalmic care. Approximately 20% are left with residual facial weakness. 3 As part of a multidisciplinary study encompassing ophthalmology, otolaryngology, and physical medicine, we examined 33 patients with Bell's palsy soon after the onset of facial paralysis to determine the nature and severity of associated ocular in vol vemen t. MATERIALS AND METHOD

Thirty-three patients (18 males, 15 females) ranging in age from .15 to 70 years, were admitted to the Clinical Study Unit of the New England Medical Center Hospital within four days of onset of Bell's palsy. The right side was involved in 18 patients, the left side in 15. In addition to other examinations, each patient underwent a complete ophthalmic examination, including Schirmer testing, measurement of corneal sensitivity, and electromyography of the muscles supplied by the five main branches of the facial nerve. No patient had had any prior eyelid taping or treatment before the ocular examination. Sixteen patients returned for follow-up study one year after onset of the palsy.

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WEPMAN AND BAUM TABLE

OPHTH AAO

1

RELATIONSHIP BETWEEN CoNJUNCTIVAL INJECTION AND CoRNEAL EPITHELIAL INVOLVEMENT

NO CORNEAL STAINING

PUNCTATE STAINING OF CORNEA

53% (13) 0% (0)

Involved eye normal (n=25) Involved eye injected (n:=8)

RESULTS

No difference in corneal sensitivity between involved and noninvolved eyes was noted. The mean intraocular pressure (lOP) by applanation tonometry was 16.2 mm Hg on the affected side and 15.9 mm Hg on the unaffected side. In no case was there a difference of greater than 3 mm Hg between eyes and no trend toward a lower lOP on the involved side could be identified.

The patients' symptoms were, in most cases, mild hut annoying. Epiphora (40%) was the most common ophthalmic complaint, followed by burning (20%), incomplete lid closure (20%), and blurred vision (6%). Fourteen percent had no ocular complaints. Fifteen patients (45%) showed no difference in best corrected visual acuity between the eye on the affected side and the eye on the unaffected side. Another 15 patients (45%) had a one line difference, the eye on the affected side having the reduced vision. Three patients (9%) showed two or more lines difference between eyes but had preexisting disease (two patients with amblyopia, one patient who had had iridocyclitis) to account for the difference.

47% (12) 100% (8)

The conjunctiva on the involved side was normal in 25 patients (76%) and mildly to moderately injected in 8 (24%). Punctate staining of the inferior cornea was noted in 20 cases (61%). In the remaining 13 patients (39%) the cornea was clear. Conjunctival injection and corneal staining are correlated in Table 1. Table 2 correlates Schirmer test results and corneal staining. The

TABLE

2

RELATIONSHIP BETWEEN ScHIRMER TEsT REsuLTS AND CORNEAL EPITHELIAL INVOLVEMENT

SCHIRMER TEST

No ·difference between eyes (n=15)* More tears (involved side) (n=9}t Fewer tears (involved side) (n=7}t *<5 mm difference. t>5 mm difference.

NO CORNEAL STAINING

PUNCTATE STAINING OF CORNEA

47% (7)

53% (8)

44% (4)

56% (5)

43% (3)

57% (4)

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TABLE 3 RELATIONSHIP BETWEEN ELECTROMYOGRAPHIC RESULTS AND CORNEAL EPITHELIAL INVOLVEMENT

NO CORNEAL STAINING

PUNCTATE STAINING OF CORNEA

33% (7)

67% (14)

75% (9)

25% (3)

Orbicularis involved (n=21) Orbicularis function normal (n=12)

nine patients who demonstrated greater tear production by Schinner testing were the same nine patients who complained of epiphora. The presence and quality of Bell's phenomenon was recorded in 25 patients. In 21 patients this phenomenon was described as good. Fourteen (67%) from this group showed punctate staining of the cornea. Three patients exhibited a fair Bell's phenomenon. Only one of these three patients showed corneal epithelial involvement. Another patient had no Bell's phenomenon; no punctate staining of the cornea was noted in this case. Electromyographic studies revealed poor orbicularis oculi function in 21 cases (64%). The orbicularis was found to function nonnally in 12 patients (36%). Table 3 compares the electromyographic results with the presence of corneal staining. At the time of the initial clinical evaluation, the degree of lagophthalmos did not correlate with either the electromyographic results or corneal staining. Patching thereafter precluded further correlation. All of the 16 patients who returned for one-year follow-up examinations had recovered complete facial nerve function. No patients complained of ocular symptoms re-

ferable to the Bell's palsy. All symptoms present at the time of the initial ocular examination abated over a one-month period. Bedtime lid taping and use of antibiotic ointments were discontinued when improvement of lid closure was noted. Ocular examination revealed recovery of visual acuity in involved eyes and complete resolution of corneal staining in all cases. No pennanent sequelae were identified. Electromyograms were not performed at the one-year follow-up examination. DISCUSSION

Peripheral paralysis of the facial nerve arises from a multiplicity of etiologic factors, including trauma, infection, and tumor. A diagnosis of Bell's palsy is established only after exclusion of these factors. This idiopathic condition is probably the most common cause of facial paralysis and affects a wide range of patients, without predilection for age or sex, as exemplified by our patient population. Fortunately, 90% of patients recover complete or nearly complete function, regardless of treatment. 3 It has been shown that increased orbicularis tone results in '.a concomitant increase in intraqcular pressure (lOP) of up to 60 mm Hg. 4

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OPHTH

AAO

Conversely, decreased orbicularis tone might be expected to decrease lOP. Losada and Wolintz5 reported 12 Bell's palsy cases in which a significant (mean of 5 mm Hg) reduction in lOP on the involved side was found. Our findings fail to confirm such a reduction in pressure. A study of the lOP following seventh nerve block also failed to demonstrate any pressure reduction.6

minor corneal involvement during the first two weeks of this condition. We found that virtually all patients with conjunctival injection showed corneal staining, but, additionally, 50% of patients with a normal conjunctival appearance also showed staining. Our colleagues from other specialties who see this condition in the acute state should then administer appropriate ocular care to prevent further complications of exposure keratitis. Liberal The results of our study suggest . use of artificial tears, antibiotic that the tone of the orbicularis oculi ointments and lid taping are indias measured by electromyographic cated until recovery of orbicularis studies is a significant factor in function is adequate to insure cormaintaining corneal epithelial in- neal epithelial integrity. tegrity in patients with Bell's palsy. Surprisingly, we did not find any ACKNOWLEDGMENT correlation between corneal epithelial integrity and some traditionally The Department of Physical Medicine and held factors felt important in the Rehabilitation of the Tufts·New England Center under the direction of Carl maintenance of corneal clarity. In Medical Granger, MD, coordinated this project and our study the presence of an ade- performed the electromyograms. quate Bell's phenomenon, adequate tear production (as measured by Schirmer testing), and clinical asREFERENCES sessment of the degree of lagoph1. Jepsen AK: Topognosis of facial nerve thalmos failed to correlate with the lesions. Arch Otolaryngol 81:449·465, 1965. predicted appearance of the corneal 2. Levine RE: Management of the eye in epithelium. The role played by the facial paralysis: Symposium on disease and orbicularis oculi muscle in the injury of the facial nerve. Otolaryngol Clin maintenance of corneal epithelial North Am 7:531·543, 1974. integrity deserves further study. 3. Duke-Elder S, Scott GI: System of Oph· Perhaps some cases in which un- thalmology, Vol XII. London, Henry Kimp· explained punctate staining of the ton, 1971, pp 916-928. inferior cornea is observed actually 4. Duke·Elder S: System of Ophthalmolrepresent derangement in orbicu- ogy, Vol IV. London, Henry Kimpton, 1968, pp 280-281. laris function, albeit subclinical. In the day to day clinical practice of ophthalmology, we rarely encounter patients with acute Bell's palsy. Our findings indicate a high frequency of ocular symptoms and

5. Losada F, Wolintz AH: Bell's palsy: A new ophthalmologic sign. Ann Ophthalmol 5:1093-1096, 1973. 6. Starrels ME, Krupin T, Burde RM: Bell's palsy and intraocular pressure. Ann Ophthalmol 7:1067-1068, 1975.