Ophthal Plast Reconstr Surg, Vol. 31, No. 6, 2015 459 Purpose: To report the results of bupivacaine injection into the orbicularis oculi muscle to treat lagophthalmos in patients with long-standing Bell palsy. Methods: In this prospective interventional case series, bupivacaine, 5 ml of a 0.750% solution, was injected into the preseptal and pretarsal area of the orbicularis oculi in each of 10 patients with idiopathic peripheral facial nerve palsy. The measures of vertical eyelid apertures during open and closed eyes were made before the procedure and 1, 3, and 6 months after injection. Results: A total of 10 eyes including 2 men and 8 women with an average age of 43 years (26–64 years) were studied. The mean amount of lagophthalmos before injection and after 6 months of follow up were 3.9 mm and 2.3 mm, respectively (p = 0.01)). The mean amount of corneal exposure before injection and after 6 months of follow up was 1.05 mm and 0.25 mm, respectively (p < 0.01). The mean scleral show in open eyes before injection and after 6 months of follow up were 1.20 mm and 0.75 mm, respectively (p = 0.08). The mean scleral show in closed eyes before injection and after 6 months of follow up were 1.95 mm and 1.15 mm, respectively (p = 0.01). All the patients reported significant decrease in epiphora. Conclusion: Bupivacaine injection in the paretic orbicularis oculi muscle improves eyelid closure and lagophthalmos and epiphora. (Ophthal Plast Reconstr Surg 2015;31:459–462) I diopathic peripheral facial nerve palsy (Bell palsy), the most common cause of facial palsy, is a devastating condition with an estimated incidence rate varying between 15 and 35 per 100,000. 1 While spontaneous recovery occurs in up to 70% of patients, functional deficit would be a serious dilemma in the remaining portion, which may result in physical and psycho- social disabilities. 2 It has been noted that 85% of this original, 70% recovered within 3 weeks of onset of paralysis and the remaining 15% recovered during the subsequent 3 to 5 months. 3 Corneal exposure keratopathy is the most important ocular complication of facial nerve palsy which may eventu- ally lead to corneal perforation. 4 Decreased blink excursion, paralytic ectropion of lower eyelid, and upper eyelid retraction have been mentioned as contributing factors. 5 Hence, several studies have investigated numerous surgical techniques includ- ing tarsorrhaphy, mullerectomy, levator marginal myotomy, full-thickness blepharotomy, levator recession, passive eyelid reanimation with gold weight implantation, and dynamic eyelid reanimation with palpebral spring placement for the manage- ment of this potentially sight-threatening outcome. 6–9 However, all these procedures are not only invasive, time-consuming, and carries a substantial risk of failure but also have their own related surgical complications. 10–12 Bupivacaine is originally an anesthetic drug which has been found guilty for inducing vertical strabismus and diplopia in patients who had been anesthetized with retrobulbar injection of bupivacaine for cataract surgery. 13,14 It has been shown that bupivacaine would be able to induce hypertrophy in extraocu- lar muscles and therefore would increase the muscle contrac- tility and stiffness. 15 This brilliant property has been fruitfully addressed in some recent studies evaluating the role of bupiva- caine injection for ocular alignment purposes. 16,17 In the present study, for the first time up to now, the authors used bupivacaine injection in orbicularis oculi muscle of 10 patients with long-standing lagophthalmos due to Bell palsy. MATERIALS AND METHODS The study was implemented in accordance with the tenets of the declaration of Helsinki. The study protocol was approved by the local eth- ics review committee of Tehran University of Medical Sciences, and all participants provided with written informed consents prior to inclusion. Study Participants. In a prospective interventional case series, 10 patients with lagophthalmos due to idiopathic facial nerve palsy were enrolled. The duration of disease should be at least 12 months with no recovery within last 6 months. The patients have partial recovery, and they have some de- gree of lagophthalmos and corneal exposure as the recovery is incomplete. Partial recovery means that there exists amount of force in orbicularis mus- cle that it is not enough to close the eyelids completely because denervated extraocular muscle does not respond well to bupivacaine. The included patients were under only conservative treatments such as lubricant drops and gel to prevent corneal breakdown, and none of the surgical maneuvers such as tarsorrhaphy has been performed on these patients. The exclusion criteria were as following: complete facial nerve palsy; traumatic causes of facial palsy; duration of less than 12 months; existence of severe corneal exposure or ulcer or patients who need immediate intervention; history of any surgical intervention to correct lagophthalmos, and simultaneous third nerve or fourth nerve palsy. Based on the House–Brackman facial nerve grading system, included patients had grade IV or V of involvement which means that there was moderate severe or severe dysfunction. 18 Method of Injection. Five milliliter Bupivacaine 0.75% (Marcaine; Carestream Dental Inc., Atlanta, GA, U.S.A.) was injected with 27-gauge needle in preseptal and pretarsal areas of orbicularis oculi muscle (3.5 ml in upper eyelid and 1.5 ml in lower eyelid) for 3 times with 2 weeks intervals. The preseptal and pretarsal areas of orbicularis oculi were injected because these parts of the muscle are responsible for DOI: 10.1097/IOP.0000000000000387 Accepted for publication November 25, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Mahla Shadravan, M.D., Eye Research Center, Farabi Eye Hospital, Qazvin Square, Tehran 1336616351, Iran. E-mail: mt_rejabi@yahoo.com Bupivacaine Injection for Management of Lagophthalmos Due to Long-Standing Idiopathic Facial Nerve Palsy Mohammad Taher Rajabi, M.D., Mahla Shadravan, M.D., Mehdi Mazloumi, M.D., M.P.H., Syed Ziaeddin Tabatabaie, M.D., Seyedeh Simindokht Hosseini, M.D., and Mohammad Bagher Rajabi, M.D. Eye Research Center, Farabi Eye Hospital, Department of Ophtalmology, Tehran University of Medical Sciences, Tehran, Iran. ORIGINAL INVESTIGATION