Eye Care

Eye Care Guide for Ramsay Hunt Syndrome

Ocular Ramsay Hunt syndrome refers to involvement of the eye and surrounding structures in Ramsay Hunt syndrome (RHS), a neurological condition caused by reactivation of the varicella-zoster virus in the facial nerve. Eye complications in RHS arise from the facial nerve's role in eyelid closure (aka blinking) and tear production. Patients with RHS often have difficulty fully closing their eye, potentially resulting in dry eye, eye irritation, corneal damage, and vision problems.

Symptoms related to the eye

In RHS, facial paralysis can make it diﬃcult or impossible to fully close the eye on the aﬀected side. This is referred to as lagophthalmos or the inability to fully close one’s eyelids.

Dry Eye

When the eyelid doesn't close properly, the eye's surface is too exposed leading to dryness, irritation, discomfort, and blurred vision. Patients with RHS often do not make enough tears exacerbating eye dryness.

Corneal Damage

Prolonged exposure to air, due to decreased ability to blink, can cause the cornea (the clear front part of the eye) to become damaged, potentially leading to corneal ulcers, infections, and even temporary or permanent vision loss. Difficulty blinking also leads to poor eye protection, and wind, dirt, and other irritants can directly damage the cornea due to this poor protection.

Excessive Tearing

In patients with RHS who have difficulty blinking, tears accumulate and spill over the lower eyelid onto the cheek. This excessive tearing (aka epiphora) occurs because blinking is necessary to spread tears across the surface of the eye and help them drain. Decreased blinking is why your eyes can feel dry, but there are tears running down your cheek at the same time. In patients with long-term (aka chronic) RHS, abnormal nerve regeneration can lead to tear production during eating. This phenomenon is known as "crocodile tears."

Management of ocular symptoms

Eye Lubrication

Artiﬁcial tears and lubricating ointments are often recommended to keep the eye surface moist and prevent drying. There are many diﬀerent over-the-counter (OTC) artiﬁcial tears. Almost any of these products will help, but ones that are preservative-free are generally tolerated the best. Also, avoid using anything that says it removes redness like Visine.

Prescription Dry Eye Treatments

In addition to many OTC dry eye treatments, there are several prescription medications that can be used to help treat dry eyes as well. There are topical drops (e.g., Meibo®), a nasal spray (Tyrvaya®), as well as some oral medications that may be beneficial. Talk with your eye doctor about these options, especially if you still have dryness after trying OTC options.

Eye Patching

Taping the eye shut at night can help protect the cornea and prevent further dryness (make sure your eye is fully closed before taping it). Taping is generally more effective than wearing an eye patch as if your eye opens under the patch, it could get scratched. As an alternative to taping, you can use a moisture chamber to protect the eye at night.

To tape your eyelids at night, you will need special cloth or paper tape that can be purchased from pharmacies or online. There is even tape made specifically for eyelid closure. The easiest way to tape your lids is to put an artificial tear lubricant in the eye first, then forcibly close the lid as much as possible. As you continue to look down, place a small piece of tape just below the upper eyebrow in a vertical position. Gently stretch the tape down towards your cheek and press it against your cheek bone to keep the lid closed. You can confirm that the lid is fully closed by shining a light towards the taped eye to see if you can perceive the light. If so, gently remove the tape and try again. If you cannot perceive light then you should be good to go. Sometimes, it can be necessary to use more than one piece of tape so keep that in mind as well.

There are OTC artiﬁcial tear gels and ointments that are for nighttime use and can help with overnight eye dryness. It’s also a good idea to make sure you don’t have excessive air blowing on your face at night from a fan above your bed or a ceiling vent. In drier climates, a humidifier can also help.

Surgical Treatments

There are also surgical options to help with dryness. A small platinum weight can be placed under the upper eyelid skin which improves eye protection and comfort. The lower eyelid can be tightened (i.e. tarsal strip procedure) to improve closure and tear drainage. Tiny plugs can be placed at the opening of the tear ducts (i.e., punctal plugs) to help conserve your own tears and artificial tears. Talk with your eye doctor, facial plastic surgeon, or ENT doctor about these options.

Provided by Dr. Scott Sikes, O.D. and Dr. Matthew Miller, M.D.