Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009

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Figure 1D: Postoperative photograph showing adequate superior fornix

complete or incomplete cryptophthalmos. There is a variable deficiency in the development of eyebrows, eyelids and adhesion of eyelids to the globe. It may also be associated with systemic anomalies like facial abnormalities or renal anomalies.

Management

Lid sharing procedure may be attempted in cases of incomplete cryptophthalmos, where one may suspect some visual potential.

Coloboma

Congenital colobomas of the eyelid is a form of facial clefting. It occurs when there is a defect in the eyelid margin due to inability of fusion of surface ectoderm to form lid folds or following mechanical trauma from amniotic bands. They may

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vary from tiny notches in the margin to a defect of half or more of the eyelid. It may be unilateral or bilateral, the upper or the lower eyelid may be involved. Upper eyelid coloboma are usually unilateral and medial. It may vary from a small notch to large coloboma which can lead to exposure keratopathy and require early repair (Figures 2 and 3). These may be associated with systemic and ocular abnormalities

Figure 2: An 8-month-old infant with congenital upper eyelid coloboma

Figure 3: Congenital upper eyelid coloboma with exposure keratopathy

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most common is the Goldenhar syndrome (limbal dermoids and dermal lipomas). Lower lid coloboma are unilateral – usually isolated and occur laterally. Bilateral coloboma are usually associated with a systemic syndrome like Treacher Collin syndrome.

Management

Surgical management in cases of coloboma without exposure keratopathy is deferred till 3-4 years of age.

Principles of management of eyelid reconstruction:

1.Direct suturing with or without cantholysis—for small defets upto 25% of full thickness

2.Tenzel’s flap for upper lid colobomas—for defects up to 40-50% of the upper lid.

3.Lid sharing procedures—for defects more than 55%

(Figures 4A to F).

Figure 4A: 9-day-old infant with upper lid coloboma with exposure keratopathy

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Figure 4B: Lid dissected away from cornea and globe

Figure 4C: Mucous membrane graft taken from buccal mucosa

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Figure 4D: Graft forming the bulbar covering and fornix

Figure 4E: Skin-muscle sutured conjunctiva inferiorly

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Figure 4F: Separation of flaps after 2 months

4.Medial canthal fixation/anchoring (in cases of lower lid colobomas) usually associated with lateral mobilization

Ankyloblepharon

Ankyloblepharon results from incomplete separation of the fused lid folds. It may be filiform or broad adhesion between the two lids (Figure 5).

Management

The adhesions can be surgically divided to increase the interpalpebral fissure.

Congenital Ectropion

Ectropion is eversion of the eyelid more so in lateral portion of the eyelid (Figure 6). It rarely occur as an isolated entity and is associated with congenital ptosis, blepharophimosis, microphthalmos or buphthalmos.

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Figure 5: An infant with filiform ankyloblepharon

Figure 6: Congenital ectropion

Management

Management may vary depending on the degree of ectropion. In case of severe ectropion skin grafting is indicated. Full thickness graft is required in case of lower lid and partial thickness for upper lid ectropion.

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Figure 7: A young girl with congenital entropion

Congenital Entropion

It is inward turning of the eyelid margin (Figure 7). It is due to absence of taral plate or hypertrophy of the marginal portion of orbicularis. Rarely it occurs as an isolated condition. Entropion may be associated with epiblepharon, epicanthus or enophthalmos.

Management

It may resolve spontaneously or may require Skin – muscle resection or tarsal fixation of the inturned tarsus or tightening of lower lid etractors.

Epiblepharon

It is a congenital condition where extra fold of skin causes the inward turning of the eyelashes with the globe (Figures 8A to D). It may regress spontaneously by the age of 5 to 10 years with the growth of facial bones.

Management

No treatment is required, if asymptomatic. A conservative skin muscle resection in cases with significant discomfort or keratitis.

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Figure 8A: Showing epiblepharon of right eye, eyelashes are not rubbing against the globe

Figure 8B: Marking for skin-muscle resection

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Figure 8C: Skin-muscle resection

Figure 8D: Postoperative photograph