Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
.pdf
Pediatric Eyelid Abnormalities 49
Figure 9: 7-year-old boy showing euryblepharon
Euryblepharon
In this condition there is horizontal enlargement of the palpebral aperture, more so in the lateral part. Lateral canthus is displaced downward along with downward displacement of temporal half of lower eyelid (Figure 9).
Management
Surgical treatment may vary depending on the downward displacement. One may treat with tarsorrhaphy or tarsal or skin graft.
Epicanthus
Epicanthal folds are redundant vertical folds of skin in the region of medial canthus, with their concavity directed towards the inner canthus.
Types of epicanthus:
1.Epicanthus tarsalis
2.Epicanthus inversus - originates in the lower lid and extends upwards to the medial canthal area. It does not resolve on its own (Figure 10).
3.Epicanthus palpebralis
50 Oculoplasty and Reconstructive Surgery
Figure 10: A 5-year-old child presented with severe ptosis with epicanthus inversus with telecanthus
It may occasionally be a isolated condition or may be associated with Blepharophimosis syndrome or Down’s syndrome. In many instances, epicanthus may resolve with growing age.
Management
Mustarde’s double “Z” plasty is the procedure of choice for epicanthus inversus. Some of the other options include “Y-V” plasty, Spaeth and Blair procedures.
Telecanthus
Normally the distance between the medial canthi is half the interpupillary distance. In telecanthus the intercanthal distance is more than half the interpupillary distance. It occurs due to increase length of medial canthal tendons resulting in increased distance between medial canthi. It is important to differentiate it from hypertelorism in that the distance between the medial wall of orbit is increased resulting in increased distance between the eyeballs. The natural course of telecanthus remains unchanged with age.
Pediatric Eyelid Abnormalities 51
Management
The condition should be repaired by either MPL placation / resection or transnasal wiring.
Congenital Ptosis
Ptosis occurs due to developmental dystrophy of unknown etiology, affecting the levator muscle.
Congenital ptosis may be classified as:
•Congenital simple ptosis (Figure 11)
•With oculomotor abnormalities
•With blepherophimosis syndrome (Figure 12)
Figure 11: A child with left eye congenital simple severe ptosis
Figure 12: Blepharophimosis syndrome showing clinical features
52 Oculoplasty and Reconstructive Surgery
•Synkinetic ptosis
•Marcus Gunn Jaw winking
•Misdirected third nerve ptosis.
Management
It is advisable to wait till 3-4 years of age as better assessment is possible at this age. Tissues are better developed to withstand surgical trauma and better postoperative care is possible due to better cooperation. However, one should not delay in surgical management in cases of severe ptosis where pupil is obstructed as it may cause amblyopia and where child is likely to develop bad postural habits like head tilt, brow wrinkling, eyebrow arching. In these cases a temporary procedure may be opted early on followed by definitive surgery later.
Choice of Surgical Procedure
Choice is determined by (Table 1):
•Whether the ptosis is unilateral or bilateral
•Severity of ptosis
•Levator action
•Simple ptosis or associated anomalies
Table 1: Indications for the choice of different surgical procedures
Ptosis |
Levator action |
Surgery |
|
|
|
Mild |
> 10 mm |
Fasanella Servat |
|
< 10 mm |
Levator resection |
Moderate |
Fair to Good |
Levator resection |
|
Poor (rare) |
Whitnall’s sling or Brow suspension |
Severe |
Fair |
Levator resection or Brow suspension |
|
|
ptosis repair |
|
Poor |
Brow suspension ptosis repair |
|
|
|
Pediatric Eyelid Abnormalities 53
Commonly Performed Surgeries
•Fasanella Servat operation
•Levator resection
•Brow suspension ptosis repair.
Congenital Tumors
Pigmented Lesions
Nevi (Figure 13)
These are benign congenital tumors. They may vary in size and may be sessile or pedunculated. The commonest location is along the lid border. Risk of malignancy is low. However, in large tumors, there will be 4-6% risk of malignant transformation. Sudden increase in size and increase in pigmentation suggests concern regarding malignant transformation and requires excision.
Figure 13: Showing nevus in upper eyelid
54 Oculoplasty and Reconstructive Surgery
Management
If naevi involves the lid margin – shave off flush with the lid margin.
If naevus does not involve the lid margin – Excision with direct repair with margin repair.
Naevus of Ota ( Oculodermal melanocytosis)
It is characterized by patchy bluish or brownish pigmentation of periocular skin and sclera. The lesion is composed of dermal melanocytes and has malignant potential. Increased intraocular pigmentation contributes to risk of glaucoma. It is occasionally associated with Sturge-Weber syndrome.
Management: Ruby laser has been tried to lighten the cutaneous component.
Angiomatous Tumors
Portwine Stain (Nevus Flammeus)
This condition is characterized by telengectesia of the deeper skin capillaries. It involves the part of the face which is innervated by the trigeminal nerve. It is often associated with Sturge-Weber syndrome. Congenital glaucoma and choroidal haemangioma have strong association. It is important to recognize such condition because of the possibility of development of above mentioned complications.
Strawberry (Capillary) Hemangioma (Figure 14)
These are benign tumors present at birth. 90% of these clinically manifest by age of 1 month. Histopathologically, these are proliferations of endothelial cells. Most commonly they involve the upper eyelid with variable extension into orbit.
Pediatric Eyelid Abnormalities 55
Figure 14: An infant with capillary hemangioma
These tumor grow for 3-6 months after birth and slowly regresses by second year of life. Spontaneous resolution occurs in 40% by 4 years of age and 80% by 8 years.
Management
Surgery is indicated in cases of total ptosis obscuring the visual axis and induced astigmatism and for better cosmesis. Intralesional injection of 1-2 ml of corticosteroid. Betamethasone 6 mg/ml and Triamcinolone 40 mg/cc combined in 1:1 concentration and is injected all around the lesion with 26G needle deep into the lesion (Figure 15). Rapid shrinkage occurs in first two weeks and then continues slowly for several months. Injection may be repeated after 6 weeks in case of residual mass. Depigmentation of overlying skin, eyelid necrosis and rarely central retinal artery occlusion are few complications seen with steroid injection.
Dermoid and Epidermoid Cyst
Abnormal sequestration of surface ectoderm beneath the skin during embryonic development results in the cyst formation. Lids are usually secondarily involved due to extension of the tumor from the orbits.
56 Oculoplasty and Reconstructive Surgery
Figure 15: Injecting corticosteroid in the hemangioma
They are clinically evident by first year of life. Most common location is superonasal. On palpation, these are firm in consistency, non-tender and are attached to underlying periosteum. Imaging is necessary to know the extension.
Management
Surgical excision is required in case of progressive enlargement of mass or to prevent inflammation following rupture of the cyst.
Plexiform Neurofibroma
Involvement of the lid with plexiform neuroma in cases of neurofibromatosis (Figure 16). Café au lait spots are characteristic of neurofibromatosis.
Pediatric Eyelid Abnormalities 57
Figure 16: Showing plexiform neurofibroma of let upper lid
Management
Surgery is indicated in cases of significant mechanical ptosis and to improve cosmesis. Surgical debulking of the mass along with ptosis correction and lateral shortening may be performed in single stage or in two stages.
ACQUIRED DISORDERS
Acquired abnormalities of eyelid can be due to – Eyelid trauma and its sequelae Inflammatory and infective disorders.
Eyelid Trauma in Children
These are commonly encountered following birth injuries, automobile accidents, fall, sports injuries, child abuse and Chemical Injuries. Following injury the child may present with lid laceration with or without marginal involvement, canalicular injuries, canthal injuries, avulsion of the eyelid, coloboma, misalignments of eyelids and many others.
58 Oculoplasty and Reconstructive Surgery
Management
It is important to properly evaluate the wound. Repair of injury depends on the time of presentation. In patients presenting within 24 hours of the injury primary repair of the wound is undertaken immediately. The primary repair affords the chance for best cosmetic and functional results. n cases where patient presents more than 24 hours after injury or in cases where there is marked lid edema or infection, a delayed primary repair is performed after 3 to 4 days. During this waiting period, cold saline compresses, anti-inflammatory and antibiotics are administered to reduce tissue edema and to control infection. In cases where the child presents a long time after injury or in cases of chemical and thermal burns healing by second intention must be allowed to take place. In such cases, atleast wait for a minimum of 5 to 6 months before planning a secondary wound repair (Figure 17).
Figure 17: Traumatic telecanthus of right eye following road traffic accidents