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To identify the risk factors associated with the development of ocular surface exposure and severe visual impairment (SVI) in patients with facial nerve palsy (FNP). Ocular data of all consecutive FNP patients (N = 1870) presenting to an eye-care network over the past 10 years were reviewed. Risk factors associated with SVI (best-corrected visual acuity &lt;20/200) and ocular surface exposure at presentation were evaluated using multivariate analysis and odds ratios (OR). The prevalence of SVI was 15%, and 47% had ocular surface exposure at the first presentation. The presence of corneal scar (28% vs. 10.2%,  p  &lt; .001; OR 3.05), corneal ulcer (12.9% vs. 2.3%,  p  &lt; .001; OR 4.67), older age at presentation ( p  &lt; .001; OR 1.02), &gt;10 mm lagophthalmos ( p  &lt; .001; OR 8.7), male sex, and duration of FNP ( p  = .021; OR 1) were independent risk factors for developing SVI. Of the 893 eyes with ocular surface exposure, 75 (3.9%) had a corneal ulcer, and 11 (0.6%) were perforated, with the rest having epithelial defects and punctate keratopathy. Patients with neoplastic etiology (15.9% vs. 5.7%;  p  &lt; .001; OR 2.39), lagophthalmos (49% vs. 29.7%;  p  &lt; .001; OR 2.25) and poor Bell’s phenomenon (9.4% vs. 4.2%;  p  = .005; OR 1.8) had twofold risk for developing ocular surface exposure. Eyes with lagophthalmos, poor Bell’s phenomenon, and FNP of neoplastic etiology have a higher risk of developing ocular surface exposure. Male sex, increasing age, longer duration of FNP, and &gt;10 mm lagophthalmos are associated with SVI in FNP patients; hence, early and timely intervention is necessary.

Ocular involvement in facial nerve paralysis: risk factors for severe visual impairment and ocular surface exposure in 1870 patients