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

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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