Purpose <p>To identify predictors of ocular complications and to investigate treatment approaches in patients with facial paralysis (FP) in Taiwan.</p> Study design <p>Retrospective database study.</p> Methods <p>Patients with FP in the Chang Gung Research Database (2001–2022) were enrolled. Primary outcomes were ocular complications, including eyelid malposition (eg, lagophthalmos, ectropion) and ocular surface diseases (eg, recurrent corneal erosion, corneal ulcer). Predictors (demographics, comorbidities, and causes of FP) were assessed by use of the Cox proportional hazards model. A hazard ratio (HR) ≥1.50 or ≤0.67 was predefined as clinically significant. Secondary outcomes included treatment approaches.</p> Results <p>Among 36,382 patients with FP, 55.38% were diagnosed with Bell palsy; 4.95%, with new stroke; and 4.55%, with head and neck injury. Ocular complications developed in 9.22% of the patients. Factors associated with increased hazard included underlying chronic obstructive pulmonary disease (HR: 1.64; 95% CI: 1.46–1.85) and causes of FP due to head and neck injury (HR: 2.47; 95% CI: 2.19–2.79), brain tumors (HR: 2.26; 95% CI: 1.93–2.66), birth trauma (HR: 1.70; 95% CI: 1.42–2.04), surgery for brain tumors (HR: 1.59; 95% CI: 1.11–2.28), and head and neck tumors (HR: 1.56; 95% CI: 1.29–1.89). Among all the causes of FP, Bell palsy was associated with the lowest hazard of ocular complications (HR: 0.81; 95% CI: 0.75–0.88). Surgeries were required in 10.35% of patients, including 1.34% for dynamic reconstruction (muscle transfer and/or neurotization), 0.98% for static eyelid surgeries (eg, eyelid malposition correction, temporary tarsorrhaphy), and 0.05% for corneal transplant.</p> Conclusion <p>Bell palsy, the predominant cause of FP, showed the lowest hazard of ocular complications, whilst head and neck injuries showed the highest hazard.</p>