Effectiveness of the Gold Weight Trial Procedure in Predicting the Ideal Weight for Lid Loading in Facial Palsy: A Prospective Study EKTA AGGARWAL, MILIND N. NAIK, AND SANTOSH G. HONAVAR ● PURPOSE: To evaluate the effectiveness of the gold weight trial procedure in predicting postoperative eyelid closure after gold weight implantation surgery for facial palsy. ● DESIGN: Prospective, interventional case series. ● METHODS: Patients with facial palsy undergoing gold weight implantation were enrolled prospectively to un- dergo the standard gold weight trial procedure. The criteria for ideal gold weight were defined before surgery as a minimum 50% reduction in lagophthalmos without induction of more than 2 mm ptosis during the trial procedure. The corrected weight (ideal gold weight  0.2 g) was implanted in the pretarsal space. The main outcome measure was reduction in lagophthalmos ac- cording to predefined criteria at six weeks after surgery. ● RESULTS: Thirty eyes of 29 patients underwent gold weight implantation. The mean age at surgery was 41.6 years, and the median predicted ideal gold weight was 1.2 g. The mean preoperative lagophthalmos of 7 mm reduced to 2.3 mm at six weeks after surgery. As defined by the success criteria, undercorrection was noted in nine eyes (30%) at six weeks after surgery. A preoperative lagophthalmos of 8 mm or more was noted in seven (77.8%) of nine eyes in the undercorrection group, compared with six (28.6%) of 21 eyes in the success group. Six of the nine failures required implant exchange. ● CONCLUSIONS: The ideal gold weight as estimated by the trial procedure (with 0.2 g correction factor) led to undercorrection in 30% cases. Undercorrection was common (78%) in patients with preoperative lagoph- thalmos of more than 8 mm. (Am J Ophthalmol 2007;xx:xxx. © 2007 by Elsevier Inc. All rights reserved.) E YELID GOLD WEIGHT IMPLANTS ARE USED COM- monly for the surgical management of permanent facial paralysis. Although several factors may con- tribute to the health of the ocular surface after facial palsy, the surgical techniques described over the years have established the reliability and safety of eyelid loading procedures. 1–7 It has been shown significantly to reduce lagophthalmos, to improve corneal coverage, and to decrease the dependence on artificial tear drops. 5,7 Several recent modifications of the implant as well as the surgical technique have been reported to minimize complica- tions. 8 –11 The success of the gold weight implantation procedure depends on accurate prediction of the ideal gold weight for a given patient. This is determined by the preoperative gold weight trial procedure, during which serial increments of trial gold weights are pasted to the pretarsal upper eyelid skin to assess the expected postoperative outcome. An ideal weight would be one that achieves adequate reduc- tion of the lagophthalmos without inducing significant mechanical ptosis. 12 Despite preoperative prediction of ideal gold weight by a trial procedure, a 27% undercorrec- tion was reported after pretarsal fixation of gold weight. 13 Hontanilla described the differences in gold weight vectors between the preoperative trial and its postoperative loca- tion, suggesting a correction factor of 0.2 g to be added to the final weight before lid loading procedure. 14 Unfortu- nately, limited reports are available that assess the effective- ness of the gold weight trial procedure in predicting the postoperative reduction in lagophthalmos. A MEDLINE search of the literature in English on eyelid loading proce- dures did not reveal any prospective study assessing the accuracy of the gold weight trial procedure in predicting the postoperative eyelid closure after gold weight implantation surgery. In this study, we used well-defined criteria to identify the ideal gold weight implant. The reduction in lago- phthalmos as assessed during the gold weight trial proce- dure was compared prospectively with that achieved six weeks after surgery. To the best of our knowledge, this is the first prospective study assessing the accuracy of the gold weight trial procedure in predicting the postoperative eyelid closure after gold weight implantation surgery. METHODS ALL PATIENTS WHO UNDERWENT EYELID GOLD WEIGHT implantation for permanent facial palsy from July 2004 through December 2006 were included in this prospective study. Patients who had prior gold weight implantation or levator recession surgery were excluded from the study. Accepted for publication Mar 15, 2007. From the Department of Ophthalmic Plastic Surgery, LV Prasad Eye Institute, Hyderabad, India. Inquiries to Milind N. Naik, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500034, India; e-mail: milind@lvpei.org © 2007 BY ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/07/$32.00 1 doi:10.1016/j.ajo.2007.03.026 ARTICLE IN PRESS