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) • sebaceous glands of eyelashes)
• Treatment • Eyelid hygiene • Topical steroid ointment • Intralesional steroid injections • Incision and drainage
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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 • Syndromic • Fraser syndrome (AR)
• Mutations in FRAS1 and FREM2 • Syndactyly • GU malformations • Orofacial clefting • MR • Musculoskeletal anomalies
• Management • Full eyelid reconstruction • Flap/graft
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Forehead skin extends over globe and onto cheek without forming eyelids
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
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Coloboma • Syndromic
• Fraser syndrome • Goldenhar syndrome • Treacher Collins syndrome • CHARGE
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Coloboma • Management
• Early lubrication • <50% eyelid, close primarily • >50% need lid sharing technique
• Caution for amblyopia
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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
sutures
BCSC
Epiblepharon
Epicanthus
• Medial canthal fold • Immature midfacial bones • Pseudoesotropia • Tarsalis
• Upper eyelid • Inversus
• Lower eyelid • Palpebralis
• Equal upper and lower eyelid BCSC
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
• Widened intercanthal distance
HypertelOrism (Telorbitism)
• 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
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Congenital Ptosis
• Theories: • Disorder of muscle development • Disorder of muscle innervation
• Pathology • Fibrosis • Decreased density of skeletal
muscles fibers
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Congenital Ptosis
Visioncarecentre.blogspot.com
• 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 • 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
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Many patient will have poor LF and need frontalis suspension
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
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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
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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