Upper Lid Retraction Repair with Platinum Weight

Procedure: The procedure shown in this video is an upper lid retraction repair with platinum weight.  Introduction: Lagophthalmos, defined as the inability to close the eyelids completely, may be secondary to eyelid paralysis, fibrosis, or infiltrative etiologies caused by trauma, surgery, tumor, stroke, infection or idiopathic causes. When patients have lagophthalmos due to facial nerve paralysis, anatomic contributing factors may include upper lid retraction, lower lid ectropion and retraction, and decreased rate and force of blinking.  In order to preserve the integrity of the cornea, correction of these deficits is of vital importance. Indications: Upper lid retraction repair with platinum weight implantation is indicated in patients who have loss of normal eyelid function leading to eyelid retraction, particularly in situations where the eyelid retraction is paralytic. Contraindications: Platinum weight implantation is contraindicated in patients with an allergy to the metals from which the weight is constructed.  Care should be taken in patients with thin or pale skin, as the bulkiness or color of the weight may show through the skin as a discoloration. If the eyelid dysfunction is due to fibrosis or infiltration of the eyelid tissues, such as in thyroid eye disease and other conditions, primary correction of the eyelid retraction should be considered, such as retractor recession, as eyelid weight implantation alone is not strong enough to overcome these forces causing eyelid retraction. Materials and Methods: In addition to the platinum or gold weight, standard eyelid surgical instrumentation is used, including specifically a corneal protective shell, small toothed forceps such as Castroviejo 0.5 mm forceps, Castroviejo needle driver, and Westcott scissors. Sutures used in this video include:  7-0 nylon, 6-0 polyglactin, and 6-0 plain gut. Results: After weight implantation, it is expected that there will be more complete eyelid closure with less lagophthalmos due to improved upper eyelid excursion.  It is important to understand that the endpoint of surgery is not necessarily 100% complete closure. On post-operative examination, it is critical to evaluate the patient with the use of fluorescein dye on the ocular surface and with the use of slit lamp biomicroscopy. The end-point of surgery is elimination of keratopathy. This may occur with a small amount of lagophthalmos still present in many patients. Conclusion: Upper lid retraction repair with platinum weight implantation can be used as treatment in patients with paralytic upper eyelid retraction.

The purpose of the upper eyelid retraction repair with platinum weight implantation is to improve keratopathy secondary to paralytic lagophthalmos and upper eyelid retraction. The inability to close the eyelids completely is critical since blinking covers the ocular surface with a layer of tears, thereby creating the moist environment necessary for maintaining the health of the cornea. Without complete eyelid closure, there is an increased risk of exposure keratopathy, which if severe may result in corneal ulceration, perforation and permanent vision loss. This is especially important for patients with pre-existing corneal disease or those with cranial nerve V deficits resulting in corneal anesthesia. Incomplete eyelid closure can be caused by paralysis of the orbicularis oculi muscle, thyroid disease, exophthalmos due to an orbital tumor, or traumatic eyelid injury.1 In order to preserve the integrity of the cornea, repair of any deficits is of vital importance. In patients with lagophthalmos due to facial nerve paralysis resulting is paralytic upper eyelid retraction, consideration must be given to methods of improving eyelid closure, which commonly include tarsorrhaphy (which may be temporary or permanent and may involve varying locations and proportions of the eyelids), placement of an eyelid spring device, or more commonly placement of an eyelid weight load. Common materials used for these eyelid weights include platinum and gold. Platinum is preferred over gold implant material for multiple reasons. It is denser than gold, thus requiring less space inside the eyelid and minimizing bulkiness. Gold can cause capsule formation requiring subsequent implant removal, whereas platinum has been anecdotally noted by many surgeons to be less allergenic resulting in fewer cases of implant exposure or extrusion.2 Platinum weight implantation for treatment of eyelid retraction is an attractive option since it is a quick, straightforward procedure that may be performed in the office setting with local anesthesia. Additionally, the procedure is reversible, cosmesis is excellent, and it produces a simulated blink. The approach used in this report involves a transcutaneous approach via the upper eyelid crease. The platinum weight is placed into the pretarsal space in a pocket created deep to the orbicularis oculi muscle. The orbicularis muscle is sutured to cover the implant and the skin is closed separately as a second layer of tissue over the weight. Indications for lid retraction repair with platinum weight involve patients who have had acute or severe loss of normal eyelid function resulting in significant exposure keratopathy. Platinum weight implantation is contraindicated in patients with an allergy to the metals from which the weight is constructed. Care should be taken in patients with thin or pale skin, as the bulkiness or color of the weight may show through the skin as a discoloration. If the eyelid dysfunction is due to fibrosis or infiltration of the eyelid tissues, such as in thyroid eye disease and other conditions, primary correction of the eyelid retraction should be considered, such as retractor recession, as eyelid weight implantation alone is not strong enough to overcome these forces causing eyelid retraction. Potential complications of weight implantation include post-operative ptosis, cosmetic dissatisfaction, migration of the weight, extrusion, implant infection, corneal ulceration and scarring, and residual eyelid retraction and lagophthalmos.3,4

Setup: Standard eyelid surgical instrumentation is used, including specifically a corneal protective shell, small toothed forceps such as Castroviejo 0.5 mm forceps, Castroviejo needle driver, and Westcott scissors.  Sutures used in this video include:  7-0 nylon to attach weight to tarsus, 6-0 polyglactin to close orbicularis oculi muscle and 6-0 plain gut to close skin. Implanted weights traditionally are gold, but there is a recent trend in preferring use of platinum weights, because of an observed decrease in tissue reactivity and extrusion in platinum weights versus gold.  Additionally, platinum is slightly denser than gold, resulting in a slightly smaller sized weight.  Some weights are identified as “thin profile” and others contain a “suture groove” allowing for recession of the suture. Preoperative workup: A medical history and complete eye examination should be performed, including slit lamp biomicroscopy and measurement of eyelid position and function. The selection of the size and weight of the implant can be estimated based on experience or through the use of trial weight sets.  The size of the weight must be very carefully chosen.  The companies selling weights provide trial sets in which there are non-sterile weights sized from about 0.6 grams to 1.8 grams.  These may be attached to the patient’s eyelid with a thin strip of tape in the office setting to determine which provides the best closure but limits the amount of induced ptosis. Anatomy and Landmarks: This surgical procedure requires an in-depth understanding of upper eyelid anatomy.  This is discussed on the procedure steps. Procedure Steps: A scleral shell to protect the cornea is placed before the start of the procedure. The patient’s natural upper eyelid crease is marked with a surgical marking pen and then incised with a No. 15 blade. A Wescott scissors is used to dissect posteriorly from the skin incision through the orbicularis muscle to the superior aspect of the tarsus and then along the anterior surface of the tarsus in order to create a pocket for the platinum weight. Care is taken to avoid damaging the lash bulbs, which are present at the inferior aspect of the tarsus.  It is important to create a pocket of the correct size to hold the weight. If the pocket is too large, the weight may shift positions. In the video, a three-holed 1.4 g platinum weight is placed into the pocket. The two-holed side is placed inferiorly. 7-0 nylon suture on a small needle is placed partial thickness through the anterior surface of the tarsus to engage each of the holes of the weight. This is fed from anterior to posterior through the weight so that the suture knot ends up buried between the weight and tarsus. The upper portion of the weight should rest at or just above the superior border of the tarsus. A double layered closure is then performed over the platinum weight. 6-0 polyglactin suture in a running fashion is used to close the orbicularis muscle anterior to the weight. Bites of orbicularis muscle are taken both above and below the weight so that there is a thick layer of muscle in front of the weight. The skin is closed with 6-0 plain gut suture in a running fashion. The scleral shell is removed at the end of the procedure and antibiotic ointment is applied. No dressing is needed.

The primary aim of a platinum eyelid weighting procedure is to improve the ability to close the upper eyelid due to paralytic etiologies of lagophthalmos resulting in exposure keratopathy.  Ideal positive results for this procedure are improvement or elimination of lagophthalmos on clinical exam without inducing significant ptosis in primary gaze. Minimal visibility or bulkiness of the implant would also suggest a positive result. Temporary post-operative ptosis due to edema is often present but should not be permanent. Potential negative outcomes include insufficient improvement of lagophthalmos resulting in continued significant keratopathy, vision changes or obstruction, allergic reaction to weight, and migration or extrusion of weight. Standard post-operative complications may include bleeding, hematoma secondary to local anesthesia, and infection.

Herein, we show that platinum weight eyelid implantation can be used to treat paralytic upper eyelid retraction. Gold weights implants have historically been the choice for treatment of all causes of lagophthalmos. However, several disadvantages for using gold material (allergy, extrusion, and migration) have led to platinum being preferred, just as it was for this case. Platinum eyelid weights have been shown to be less visible/bulky owing to its inherent higher density compared to gold, which allows the use of thinner implants. It has also been shown to have lower extrusion rates compared with gold, and some evidence that it is less prone to capsule formation.5 The critical steps of this procedure are outlined as follows. During the initial transcutaneous dissection through the orbicularis muscle, it is important to go straight posteriorly to the top of the tarsus, rather than angulate through the orbicularis muscle. This becomes important after the platinum weight is sutured down, as this provides a flap of orbicularis muscle to cover the weight and helps prevent future exposure or extrusion.  When dissecting to create the pretarsal space, the pocket must be of optimal size corresponding to the size of the implant. If the pocket is too large, the weight can potentially shift. The patient in this procedure had a tall tarsus (as noted on video), which made it ideal for suture placement. If there is not enough tarsus to anchor the weight, via the superior suture hole, a small partial thickness bite of the soft tissue in the area can be used. Once the weight is fully sutured to the tarsus, the closure for this procedure involved a double layer approach. If it is not a tight, multilayer closure, patients can be at a higher risk for exposure and extrusion. It is important to consider giving an oral antibiotic to these patients after the surgery because a foreign body is being placed. Topical antibiotic ointment such as erythromycin or bacitracin ophthalmic ointment should be applied to the incision and ocular surface. A primary limitation of this procedure is that it should be performed by surgeons experienced with eyelid surgery.  Many adverse events may occur if there is inadequate knowledge of anatomy, such as suturing the septum or placing the weight in a location that will allow for deep erosion and corneal touch.  Although implanting weights helps with paralyzed upper eyelid, these procedures can potentially be limited in patients with brow droop or lower eyelid disease such as ectropion. Thus, a lower lid tightening procedure should be considered to restore maximal eyelid function and corneal protection.6

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1. Rozen S, Lehrman C. Upper eyelid postseptal weight placement for treatment of paralytic lagophthalmos. Plast Reconstr Surg. 2013;131(6):1253-1265. doi:10.1097/PRS.0b013e31828be961 2. Oh TS, Min K, Song SY, Choi JW, Koh KS. Upper eyelid platinum weight placement for the treatment of paralytic lagophthalmos: A new plane between the inner septum and the levator aponeurosis. Arch Plast Surg. 2018;45(3):222-228. doi:10.5999/aps.2017.01599 3. Harrisberg BP, Singh RP, Croxson GR, Taylor RF, McCluskey PJ. Long-term outcome of gold eyelid weights in patients with facial nerve palsy. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol. 2001;22(3):397-400 4. Dinces EA, Mauriello JA, Kwartler JA, Franklin M. Complications of gold weight eyelid implants for treatment of fifth and seventh nerve paralysis. The Laryngoscope. 1997;107(12 Pt 1):1617-1622 5. Silver AL, Lindsay RW, Cheney ML, Hadlock TA. Thin-profile platinum eyelid weighting: a superior option in the paralyzed eye. Plast Reconstr Surg. 2009;123(6):1697-1703. doi:10.1097/PRS.0b013e3181a65a56 6. May M. Gold Weight and Wire Spring Implants as Alternatives to Tarsorrhaphy. Arch Otolaryngol Neck Surg. 1987;113(6):656-660. doi:10.1001/archotol.1987.01860060082020