CADS as a Decision-making Tool: Developing an Oculoplastic Management Algorithm for Facial Nerve Palsy

Abstract

Purpose: The Cornea, Asymmetry, Dynamic, Synkinesis (CADS) score is a validated grading score for periocular involvement in facial nerve palsy (FNP). We conducted a retrospective review of FNP cases, including initial CADS scores and subsequent ophthalmic interventions. The results were used to inform the development of an oculoplastic management algorithm for FNP. Methods: Single-center retrospective cohort study of patients with FNP referred to a tertiary unit between 2016 and 2022. Data collected included demographic data, etiology of FNP, treatment initiated, and CADS grading at each visit. Adult patients with ≥6 months of follow-up were included, and cases were excluded if ocular surface or oculoplastic procedures were performed elsewhere prior to the initial review by the unit. Results: Of 408 consecutive new patients with FNP, 80 fulfilled inclusion criteria (mean age 57 years, range 21–83 years). Presentations of FNP were unilateral in 98.8% (79/80), with an underlying preganglionic etiology in 75.0% (60/80). At the initial review, surgery was recommended for 61.3% (49/80) of cases. Subgroup analysis of surgical cases for each CADS domain showed 46.9% (23/49) had C-score ≥2, which was predictive of upper lid surgery requirement (e.g., upper lid platinum segment chain; levator recession). About 63.2% (31/49) had an A-score ≥1 which predicted for lower lid surgery requirement (e.g., retractor recession, lower lid sling, medial canthal tendon plication, and lower lid full thickness skin graft) as well as a brow lift. Almost 79.6% (39/49) had a D-score ≥2, which was associated with both upper lid and lower lid surgery requirements. Also, 59.2% (29/49) had an S-score of ≥1 however, this was not associated with the surgical requirement, highlighting a different approach compared with the other CADS domains. Conclusion: This study represents a large cohort of patients followed up with a validated ophthalmic-specific FNP grading scale. This was utilized to develop a CADS-based management algorithm to help guide decision-making for surgical intervention versus medical management in FNP.