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Functional Lid Surgery in Down's Syndrome

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Functional Lid Surgery in Down's Syndrome Br J Ophthalmol: first published as 10.1136/bjo.73.7.494 on 1 July 1989. Downloaded from British Journal of Ophthalmology, 1989, 73, 494-497 Functional lid surgery in Down's syndrome R J MORRIS AND J R 0 COLLIN From Moorfields Eye Hospital, City Road, London ECI SUMMARY Down's syndrome is associated with characteristic eyelid abnormalities. Ten patients presented with lid abnormalities leading to corneal problems. Five patients had ectropion, four of whom required skin grafting to correct the abnormality. One patient had entropion and four had chronic blepharoconjunctivitis leading to trichiasis, which was treated with double freeze thaw cryotherapy. Down's syndrome is associated with a wide variety of ECTROPION GROUP (FIVE PATIENTS) anatomical and biochemical abnormalities including Four patients had bilateral upper and lower lid congenital mental retardation, congenital heart ectropion as a result of severe lid skin shortage (Fig. defects, immune-system deficiencies, and ocular 1), and two developed spontaneous eversion of the abnormalities-most commonly cataracts, kerato- lids during sleep and on crying (Fig. 2). All had poor conus, Brushfield spots, and strabismus. The lid closure, with an inadequate blink response and incidence of the disease is approximately 1 in 700 live signs of bilateral corneal exposure in the interpal- births and becomes greater with increasing parental pebral zone. Three patients, all of whom had had age.' The characteristic facial features associated previous bilateral tarsorrhaphies which had broken with Down's syndrome include macroglossia, down and failed to provide adequate corneal protec- hypotonia of the lower lip, receding chin, hypoplasia tion, developed permanent corneal scarring in the of the nasal bridge, epicanthic folds, oblique lid axis, interpalpebral zone (Fig. 3); one of these had http://bjo.bmj.com/ and dysplastic ears. In 1977 Hohler described a case developed a corneal abscess. The ectropion was of a girl with Down's syndrome in whom he under- treated in all cases with full thickness skin grafting to took facial plastic surgery purely for cosmesis,2 and correct the skin shortage, postauricular skin being since then there have been other reports describing used as the donor site (Fig. 4). In three patients all the results of cosmetic facial plastic surgery for four lids were grafted and in the other patient Down's syndrome.' In some cases however, the postauricular Wolf grafts to the upper lids were combined with recession of the levator palpebrae characteristic lid abnormalities may require correc- on September 23, 2021 by guest. Protected copyright. tion for functional reasons. In particular, ectropion superiors. Although there was skin shortage of the due to skin shortage may lead to corneal exposure, lower lids, it was not considered severe enough to and trichiasis resulting from chronic blepharitis may warrant surgery. Four years later this patient required similarly lead to corneal problems. further surgery as result of corneal exposure. Conse- We report on 10 patients who presented with lid quently bilateral lower lid scleral grafts and skin abnormalities leading to corneal problems, nine of grafts from the upper arm, together with bilateral whom underwent lid surgery. Patients and methods Fifty four patients with Down's syndrome who had attended the hospital were studied; of these 10 had eyelid problems directly related to their disease, and the rest had other congenital ocular abnormalities. There were five male and five female patients. The age range at presentation was 7 months to 55 years. Correspondence to J R 0 Collin, Moorfields Eye Hospital, City Road, London EC1V 2PD. Fig. 1 Child with upper and lower lid ectropion. 494 Br J Ophthalmol: first published as 10.1136/bjo.73.7.494 on 1 July 1989. Downloaded from Functional lid surgery in Down's syndrome 495 Fig..2. Spontaneou.| e in oft.lids.. n ......... Fig. 2 Spontaneous eversion1 oftds lides own crying. Fig. 3 Patient with upper and lower lid ectropion, bilateral tarsorrhaphies, and corneal scarring. lower lid shortening~~~~~~~~.for excess lid laxity, were performed. In another patient lid skin grafting was combined with division of tarsorrhaphies and coccus (one patient). One of this group had been horizontal shortening of the lower lids (Fig. 5). referred for corneal grafting for keratoconus but had The fifth patient with ectropion in this group was been found to have trichiasis and lash ptosis which a 55-year-old man. He had bilateral lower lid needed correction prior to corneal surgery. The ectropion, bilateral blepharitis, madarosis, and trichiasis in these patients was treated with double corneal scarring in the interpalpebral area. However, freeze thaw cryotherapy to the lid margin. The lid the lid abnormalities were not considered severe was frozen from the lid surface with a special probe to enough to warrant surgery, and he was treated with a temperature of -200C; the tissues were then ocular lubricants alone. allowed to thaw spontaneously and the freeze thaw cycle was repeated. The temperature was monitered ENTROPION GROUP (ONE PATIENT) with a thermocouple needle placed deep to An 11-year-old girl presented with epiphora. On orbicularis oculi and superficial to the tarsal plate in examination she had bilateral upper and lower lid the region of the lash follicles. One patient had entropion more marked medially, with punctate electrolysis to two isolated lashes on the right upper staining of both corneas. The entropion was lid in addition to cryotherapy of the other lids. http://bjo.bmj.com/ corrected surgically with an anterior lamellar repositioning of the upper lids and plication of the Results lower lid retractors (Jones type procedure). Ectropion group. In the four patients who underwent TRICHIASIS GROUP (FOUR PATIENTS) full thickness skin grafting the surgery corrected the Four adult patients had trichiasis leading to surface ectropion as well as enabling good lid closure and corneal changes, but not associated with any improved corneal protection (Fig. 4). In all these on September 23, 2021 by guest. Protected copyright. malposition of the lid. Their ages were 15, 22, 27, and cases the signs of corneal exposure resolved, though 54 years. In each case the trichiasis was associated in three patients there was residual corneal scarring with severe chronic blepharitis, and a variety of (Fig. 5). The cosmetic results of skin grafting in these organisms were identified from lid margin cultures, young children were not good but improved with including Staphylococcus epidermidis (three time. One patient in this group with ectropion, a 55- patients), Haemophilus influenza (one patient), and year-old man, did not require surgery but responded Corynebacterium xerosis and a haemolytic strepto- well to treatment with ocular lubricants alone. Fig. 4 Same patient as in Fig. I postoperatively. Fig. 5 Same patient as in Figs. 2 and 3 postoperatively. Br J Ophthalmol: first published as 10.1136/bjo.73.7.494 on 1 July 1989. Downloaded from 496 R J Morris andJ R 0 Collin Entropion group. Surgery corrected both upper skin, and even in young babies adequate skin is and lower lid entropion in this case. usually present. Other possible donor sites include Trichiasis group. Cryotherapy was effective in skin from the supraclavicular fossa or upper inner controlling the trichiasis in all four patients with no arm. Our results show that this is an effective way of recurrences. The patient with keratoconus subse- correcting the ectropion and poor lid closure, thereby quently underwent successful bilateral penetrating preventing corneal exposure. keratoplasty. In long-standing and severe cases additional surgical procedures may be necessary fully to correct Discussion the ectropion. If excess lid laxity is present, a full thickness horizontal wedge resection can be per- Congenital ectropion is a well recognised and poten- formed at the same time as skin grafting, or may be tially sight threatening condition seen in children necessary if the ectropion recurs. In other cases skin with Down's syndrome but rarely other children. grafting with or without a horizontal lid resection Many cases respond to conservative treatment may be combined with a lid lengthening procedure if alone,7 but in children with Down's syndrome correction of the ectropion alone does not result in surgical correction is often necessary.89 In this adequate lid cover. The upper lid may be lowered, study four of our fifty-four patients had congenital provided the skin shortage is also corrected, by ectropion leading to corneal exposure and requiring tarsotomy, recession of levator palpebrae superioris, surgery. Two cases were severe enough to lead to or scleral grafting, depending on the degree of lid spontaneous eversion of the lids, which increased on lengthening required. The lower lid may be raised by forced lid closure. In three patients lagophthalmos interposing a scleral graft between the anterior lid and associated corneal exposure led to corneal retractors and the lower border of the tarsus. ulceration and permanent scarring; in one case it was The patient with ectropion who did not require severe enough to lead to a corneal abscess and surgery was an adult with involutional ectropion, hypopyon. It is therefore imperative that cases with which was not therefore associated with skin significant corneal exposure are treated promptly shortage. with appropriate surgical techniques to prevent any In the older patient with Down's syndrome chronic permanent corneal complications. blepharoconjunctivitis may lead to the development In these patients the mechanism for the ectropion of cicatricial entropion and trichiasis. Four of our was skin shortage of the lids leading to vertical patients were adults with long-standing blepharitis, shortening of the anterior lid lamella, which pulls the and all showed signs ofcorneal disturbance as a result http://bjo.bmj.com/ lid margin away from the globe and results in of the trichiasis. If neglected, such corneal changes ectropion. Associated conjunctival inflammation and may progress and corneal suppuration develop.
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