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Pediatric Eyelid Disorders

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Pediatric Eyelid Disorders Pediatric Eyelid Disorders Peter MacIntosh, MD Ophthalmic Plastic & Reconstructive Surgery February 8, 2018 Chalazia • Chronic lipogranulomatous inflammation of the eyelid • Caused by plugging of • meibomian glands (internal chalazia) • Zeis glands (external chalazia) www.drduerksen.com • sebaceous glands of eyelashes) • Treatment • Eyelid hygiene • Topical steroid ointment • Intralesional steroid injections • Incision and drainage www.surgicalpathologyatlas.com Hordeola • Acute infectious abscess of eyelid • Usually staphylococcal • Can affect • Gland of zeis (external) • Meibomian gland (internal) • Hordeola often evolve into chalazia • Treatment • Eyelid hygiene • Topical steroid/antibiotic ointment • Systemic Abx for cellulitis • Incision and drainage en.wikipedia.org/wiki/Stye Milia • Multiple tiny, white lesions • Common in infancy • Primary • on facial skin with hair follicles • Secondary • Pilosebaceous unit trauma • Pathology • Epidermoid cyst filled with keratin • Treatment • Observe • Incision with a sharp needle and expression of contents Molluscum Contangiosum • Pearly round papule • Central umbilicated • Follicular conjunctivitis • Pathology • Pox viral infection • Epidermal hyperplasia • Henderson-Patterson bodies • Eosinophilic inclusions containing virus • Treatment • Observation • Excision • Cryotherapy • Curettage • Associations • In adults, consider AIDS Cryptophthalmos ”Hidden Eye” • Sporadic Forehead skin extends over globe and onto cheek without forming eyelids • Syndromic • Fraser syndrome (AR) • Mutations in FRAS1 and FREM2 • Syndactyly • GU malformations • Orofacial clefting • MR • Musculoskeletal anomalies • Management • Full eyelid reconstruction • Flap/graft 6 Coloboma • 0.7 / 10,000 live births • Isolated • Unilateral • Usually upper eyelid • +/- corneal palpebral adhesions • Mechanical forces e.g. amniotic membrane band • Embryological error in ectodermal or mesodermal migration 7 Coloboma • Syndromic • Fraser syndrome • Goldenhar syndrome • Treacher Collins syndrome • CHARGE www.nature.com Reviewofophthalmology.com 8 Coloboma • Management • Early lubrication • <50% eyelid, close primarily • >50% need lid sharing technique • Caution for amblyopia 9 Ankyloblepharon • Web of skin • Partial or complete eyelid fusion • Management • Clamp then cut with scissors BCSC Epiblepharon Epiblepharon • Lower eyelid pretarsal muscle and skin override lid margin • Management • Observation if no K issues • Often resolves with facial maturity • Small skin/muscle excision • Anterior lamellar everting BCSC sutures Epiblepharon Epicanthus • Medial canthal fold • Immature midfacial bones • Pseudoesotropia • Tarsalis • Upper eyelid • Inversus • Lower eyelid • Palpebralis BCSC • Equal upper and lower eyelid Epicanthus Management • Observation • Often resolves with facial maturity • Z plasty • Y-V plasty • ”Jumping man” plasty Mustardé, 1963 Euryblepharon • Horizontal widening of the palpebral fissure • Inferior displacement of lateral canthal tendon • Antimongoloid slant • Management • Lateral tarsal strip BCSC Congenital Blepharophimosis Syndrome BCSC Congenital Blepharophimosis Syndrome • Ptosis BCSC Congenital Blepharophimosis Syndrome • Ptosis • Epicanthus inversus BCSC Congenital Blepharophimosis Syndrome • Ptosis • Epicanthus inversus • Telecanthus BCSC Telecanthus versus Hypertelorism Telecanthus HypertelOrism (Telorbitism) • Widened intercanthal distance • Widened interorbital distance and increased interpupillary distance BCSC Congenital Blepharophimosis Syndrome • Ptosis • Epicanthus inversus • Telecanthus • Autodomal Dominant BCSC Congenital Blepharophimosis Syndrome • Ptosis • Frontalis suspension • Hypertelorism and epicanthus inversus • Medial canthoplasty with Z- or Y-V-plasties • Transnasal wiring Tarsal Kink Syndrome • Primary congenital entropion is very rare • Usually involves medial lower eyelid • Tarsal kink may result in upper eyelid entropion • Related to • 90 degree angle in tarsus (kink) • Management • Horizontal incision though kink • Everting sutures 24 Congenital Ptosis • Theories: • Disorder of muscle development • Disorder of muscle innervation • Pathology • Fibrosis • Decreased density of skeletal muscles fibers 25 Congenital Ptosis • Characteristic findings: • Absent or poorly developed eyelid crease • Decreased levator function • Eyelid lag in down gaze Visioncarecentre.blogspot.com Congenital Ptosis • Characteristic findings: • Absent or poorly developed eyelid crease • Decreased levator function • Eyelid lag in down gaze Congenital Ptosis • Characteristic findings: • Absent or poorly developed eyelid crease • Decreased levator function • Eyelid lag in down gaze Congenital Ptosis • Management • Vision unaffected: observe • Head posturing/cosmetic • Surgery after 6 months if possible 30 Many patient will have poor LF and need frontalis suspension 31 Frontalis Suspension Sling Materials • Silicone 74.3% • Autogenous fascia lata 34.9% • Cadaveric fascia lata 25.1% • Supramid 13.3% Aakalu VK, Setabutr P. Current Ptosis Management: A National Survey of ASOPRS Members. Ophthal Plast Reconstr Surg. 2011 Feb 22. Ophthal Plast Reconstr Surg. 2011 Jul- Aug;27(4):270-6 Frontalis Suspension 34 Unilateral versus bilateral surgery for unilateral ptosis • Controversial • Do unilateral frontalis surgery to avoid surgery on the normal eye • Do bilateral frontalis surgery without excision of levator muscle on normal side • Do bilateral frontalis surgery with excision of levator muscle on normal side • Difficult to convince family to do surgery on normal side • Mostly do unilateral frontalis suspension Conclusion • Many pediatric eyelid lesions are benign • Manage corneal exposure in patients with coloboma • In congenital ptosis, remember to measure: • Lid crease • Levator function • Lag in down gaze 37 .
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