Ординатура / Офтальмология / Английские материалы / Pediatric Opthalmology_Mukherjee_2005

is rounded; the lashes arise from the anterior border in two or three rows. The upper lid being larger has more and longer lashes than lower lid. At the base of the lashes open the modified sebaceous glands the glands of Moll and Zeis.

The glands of Moll are modified apocrine sweat glands that pour the secretion in the lash follicle. The glands of Zeis have no lumen they produce lipid.

The skin of the lid and conjunctiva merge with each other on the lid margin hence it has characteristics of both skin and conjunctiva and called inter marginal strip. The orifices of the meibomian glands open on the lid margin behind the lashes. There is a faint grey line along the lid margin. The lid can be surgically split into two halves, the anterior containing skin and orbicularis and the posterior containing tarsus and conjunctiva along this line.

THE BLOOD SUPPLY

The lids have very rich blood supply this is the cause of rapid healing of lid wounds. The lids get their arterial supply from both internal and external carotid arteries. The blood supply is broadly divided in superficial system and deeper system the former is again divided into facial and orbital groups. The arteries of the lid ultimately form two arterial arcades in each lid, one above the tarsal plate and other near the lid margin.

THE VENOUS DRAINAGE

The lids have two types of venous drainage i.e. in the pretarsal and retrotarsal, which drain in external juglar, cavernous sinus and pterygoid plexus.

THE LYMPHATIC DRAINAGE

The lymphatic from lateral half drain into pre auricular nodes. Those from medial side drain in sub mandibullar group of nodes.

THE NERVE SUPPLY

The motor supply is from facial and oculomotor, the sensory is from trigeminal, the nerve to Muller’s muscles is via sympathetic.

CONGENITAL ANOMALIES OF THE LIDS38,39,40,41

A. Congenital anomalies of the lids are generally bilateral and symmetrical, unilateral congenital anomaly is no exception. The congenital anomalies may be confined to the lid or may be associated with other anomalies of globe and systemic anomalies. A common combination is congenital anomalies of lid with cranio facial and mandibulo facial deformity. Children with congenital lid anomalies are brought to physician generally for cosmetic blemish or exposure of the globe. However, an anomalous lid, if it covers the pupil may result in

amblyopia that requires early management. Large exposure of the globe due to coloboma of upper lid may also require urgent treatment.

B. Congenital anomalies of lid can be :

1.Deformity of lid margin

(a) Coloboma

(b) Ankyloplepharon (c) Distichiasis

(d) Entropion (e) Ectopion

2.Deformity of the interpalpebral aperture

(a) Telecanthus (b) Epicanthus

(c) Blepharo phimosis (d) Euriblepharon

3.Congenital Ptosis and allied conditions

4.Disorders of the lid skin

(a) Blepharochalasis (b) Epiblepharon

5.Minor and rare deformities

1. Deformity of Lid Margin

(a) Coloboma of the lid. Coloboma of upper lids result due to improper fusion of medial and frontonasal mesodermal process of face and are situated in the medial one third of the upper lid in the form of a small notch or as one extending considerably upwards. The colobomas generally have a broad base at the lid margin; it may involve the upper punctum and canaliculus. However, a large rectangular defect may develop in the middle of the lid, exposing upper part of the globe and conjunctiva. Coloboma of upper lid is generally unilateral. It is not uncommon to find other congenital anomalies in the same eye i.e. corneal opacity, microphthalmos, coloboma of the pupil. Dermoid or dermolipoma may be present in Goldenhars Syndrome. The lower lid colobomas are seen at the lateral third of lower lid, they are not so well demarcated as coloboma of the upper lip and may be missed unless carefully looked. Lower lid colobomas are wider and shallower; they by themselves are almost symptom less. They are a constant feature of mandibulo facial syndrome i.e. TreacherCollin, Franceschetti syndrome.

(b) Ankyloblepharon. The lids are fused between third and sixth month intra uterine life and start separating with development of cilia and glands of the lid. The separation starts from the middle and spreads on each side. The separation is complete at the time of birth. Some times few strands of skin may extend upon the inter palpebral aperture attached to the other lid, these strands are called ankyloblepharon. They are more common on the lateral side, may present as a single skin tag or there may be four or five strands. These are called ankyloblepharon filiformis adnatum. Medial strands are less common, central are least

common. The strands do not contain any other tissue except skin and few capillaries. The strands can be cut without difficulty soon after birth.

(c) Distichiasis. This is a rare congenital condition where orifices of meibomian glands are replaced by an extra line of cilia in addition to normal three or four that are present at the anterior rounded border of lid. There is an intact inter marginal strip between normal lashes and distichiasis. The distichiatic lashes grow posteriorly and rub against the cornea and conjunctiva. It is not uncommon to confuse them with cicatricial trichiasis in adults. In cicatricial trichiasis, the in turned lashes arise from the anterior margin of the lid. Treatment consists of repeated epilation when they are a few other wise plastic procedures are required to turn the lashed forwards.

(d) Entropion. Congenital entropion lids are very rare. They are more common in females, frequently seen with epicanthicfold, they may be confused with epiblepharon, distichiasis and trichiasis.

(e) Ectropion. Congenital ectropion is also rare. This is due to vertical shortening of the lid skin following change in subcutaneous tissue. All the lids may be involved; it is more common on the lateral side. It may be present as an isolated defect or may be associated with blepharophimosis, telecanthus, epicanthus inverses or ptosis.

2. Deformity of the Interpalpebral Aperture

(a) Telecanthus. Telecanthus is lateral displacement of medial canthi due to abnormal lengthening of medial canthal ligament . It is generally bilateral. Normal inter canthal distance is generally half of inter pupillary distance. In telecanthus this increases proportionately. True telecanthus must be differentiated from hypertelorism which is increased distance between two orbits Telecanthus may be associated with epicanthus. It is also seen in Waardenburgs syndrome. Isolated telecanthus does not produce any symptom and does not require any treatment.

(b) Epicanthus. This bilateral symmetrical congenital anomaly is very common in otherwise normal infants and disappear with age. It is a distinct feature of oriental races. It is a consistent finding in Down’s syndrome Epicanthus is seen as a vertical semilunar fold of skin on the medial side of the palpebral aperture with concavety towards the cornea. According to its extent, it can be :

Epicanthus supraciliary when the skin folds starts just below the eyebrow.

Epicanthus palpebralis, here the lid fold starts at the level of normal lid fold this is the commonest type of epicanthus.

Epicanthus tarsalis, here the lid fold starts at the level of upper border of tarsus.

Epicanthus inverses are same as any epicanthus only difference being that skin folds starts from the crease of the lower lid.

Simple epicanthus is almost symptom free. the children are brought for cosmetic blemish. Large epicanthus fold causes pseudo convergent squint that disappears on abliterating the epicanthal fold. In most of the children the epicanthus disappears with age. Ptosis with epicantus is a common presentation Blepharophimosis, ptosis, telecanthus and epicanthus inversus represent Komoto’s Tetrad42.

Differential diagnosis consists of epiblebharon where there is no superior palpebral fold but there may be trichiasis. Epicanthus may be associated with punctal stenosis. There may be amblyopia due to associated ptosis. Rarely there may be trichiasis.

(c) Blepharophimosis. This is congenital reduction of length and width of interpalpebral fissure. This is always bilateral and symmetrical. There is no defect in muscles. Simple blepharophimosis is rare. It is generally associated with epicanthus inversus, telecanthus and ptosis. The child keeps the chin raised and there are prominent furrows on the forehead to compensate associated ptosis. Blepharophimosis may give impression of pseudo convergent squint. It is corrected for cosmetic reasons by oculoplasitc repair, multiple surgeries may be required.

(d) Euriblepharon (Euryblepharon). In this case there is uniform enlargement of interpalpebral fissure, there is displacement of outer canthus laterally. This condition should not be confused with other causes of enlargement of IPA i.e. lagophthalmos, proptosis, ectropion, congenital coloboma of lower lid.

3.Congenital Ptosis and Allied Disorders. See page 43.

4.Disorders of the lid skin

(a) Blepharochalasis. This is generally familial bilateral condition where there is atrophy of the dermis of the upper lid skin that hangs loose. The orbital fat may protrude in to the overhanging skin, covering the pupil. It can be congenital or juvenile. The juvenile form starts between seven to twenty years with episodic attacks of lid swelling

(b) Epiblepharon. This is a congenital condition where there is a horizontal fold of skin either in the upper or lower lid that runs parallel to the lid margin, lower epiblepharon is more common. It may be associated with congenital entropion of lower lid.

5. Minor and Rare Deformities

(a) Ablepharon (Cryptophthalmia). A very rare condition in which there is failure of lid folds to develop in to lid. The skin of the face passes over a deformed eyeball to the cheek without inter-palpebral aperture.

(b) Microblepharon. In this case the vertical distance of the lid is short both lids, may be involved. There is mild lagophthalmos. When the patient sleeps a part of the lower bulbar conjunctiva may be visible.

(c) Mongoloid obliquity of lid is up and outward obliquity of the outer canthus. This is a constant feature of monogolism.

(d) Anti mongoloid Obliquity is downward displacement of outer canthus.

CONGENITAL PTOSIS AND ALLIED CONDITIONS

A. Congenital ptosis is commonest congenital anomaly of the lid for which a child may be brought, specially seeking treatment for cosmetic defect. It may be present at birth but not much attention is given to ptosis, as the neonate keeps the eyes closed most of the time and normal palpebral fissure is very narrow as compared to adults. However by three months of

age the parents become aware of ptosis especially if it is unilateral. Many a times a child may reach second decade not being aware of ptosis in mild cases. Congenital ptosis has strong hereditary tendency.

B.Most of the congenital ptosis are due to mal-development of the levator palpebral superior. However congenital mal-development of third nerve nucleus or its trunk may be a contributory factor. In very small number of cases, congenital Horner’s Syndrome is seen. Myogenic cause especially neonatal myasthenia may present as ptosis, so may more rare myotonia.

C.Congenital ptosis can be simple unassociated with other extra ocular muscle palsy or may be associated with

1.Superior rectus palsy,

2.Superior rectus and inferior oblique under action,

3.Other extra ocular muscle palsy.

4.It can be associated with other deformities of the lid like epicanthus, blepharophimosis

D. Simple congenital ptosis may be unilateral or bilateral. Both the sexes are equally affected. Generally there is normal vision, accommodation and pupillary reaction. A miotic pupil with ptosis points towards Horner’s syndrome. Generally levators function is moderate to mild in congenital ptosis and remains unaffected throughout life. It is not only the elevation that is subnormal downward movement of the lid is also defective (lid lag). These changes are due to dystrophic changes in L.P.S., Lid lag is not seen in any other ptosis except congenital ptosis.

Though vision is unaffected amblyopia may develop due to

1.The lid covering the pupillary area

2.Associated myopic astigmatism.

3.Associated strabismus.

In orders to have better vision the child uses frontalis, which elevates the lid slightly. Action of the frontalis can be obliterated by pressing this muscle against the frontal bone. This procedure is utilised to measure levator function. The use of frontalis by a child with ptosis throws the forehead skin into deep horizontal furrows and raises the eyebrow in an arched form. Throwing the head back (chin up) helps to compensate lowered position of lid. Raising of chin and arching of eye brow develop with age. They are more marked in bilateral cases.

E.Congenital ptosis with superior rectus under action is frequent. Superior rectus and levator palpebral superior develop from same mesodermal mass hence identical dystrophic changes may develop in superior rectus in case of congenital ptosis. Involvement of other extra ocular muscle may be central in origin. The patient may be unable to elevate the globe with ptosis hence it is mandatory that in cases of ptosis action of the superior rectus should also be evaluated. Uniocular and binocular movements of all other extra ocular muscles and orbicularis should also be tested along with corneal sensation this has prognostic importance in surgery.

F.Synkinetic movements of the lid. Paradoxical movement of the lid is generally

present with congenital ptosis. It may be present without ptosis as well

1.Synkinetic movement of lid with ptosis (Jaw winking), Marcus Gunn phenomenon. This is the commonest congenital paradoxical movement of the lid. This is seen with congenital ptosis in infancy. The mother notices abnormal movement of the upper lid in an act of sucking. The paradoxical movement persists for rest of life. It is always unilateral. In primary position, with mouth closed there is mild ptosis as the patient opens the mouth the lid drifts upwards. Raised position of the lid is not maintained if the mouth is kept open. If the jaw is moved towards the side of effected eye, ptosis increases. Sometimes forward protrusion of the jaw may produce same phenomenon Marcus Gunn phenomenon is seen only on sucking or chewing, it is not seen on smiling or coughing. The cause of this phenomenon is congenital misdirection of some of the fibers of trigeminal that supply the pterygoid muscle, to the oculomotor nerve.

2.Synkinetic movements of the lids, with out congentical ptosis

(a) Movement of the upper lid with contraction of medial rectus (b) Movement of the lid on contraction of lateral rectus

(c) Raising of upper lid on contraction of inferior rectus i.e. looking down.

ACQUIRED DISORDERS OF THE LIDS IN CHILDREN

Acquired disorders of the lids in the children can be

A.Non Specific like as

1.Edema

2.Ecchymosis

3.Change of colour.

B.Specific like

1.Infection

2.Inflammation

3.Injury

4.New growth

5.Vascular

6.Neurological.

A. Non Specific

1. Edema. Edema of the lids is a common feature of lid due to divers cause that can be : (a) Inflammatory

(b) Allergic

(c) Systemic

(d) Traumatic - Blunt, thermal, chemical, radiation. (a) The Inflammatory Causes of the Lids may be

(i) Infection of the lids.

●Bacterial-lid abscess, cellulitis lid, stye.

●Viral-herpeszoster, herpessimplex, chickenpox, measles, molluscum.

●Fungal.

●Parasitic.

(ii) Infection of globe

●Severe uveitis

●Endophthalmitis

●Purulent conjunctivitis

●Panophthalmitis

●Epidermic conjunctivitis. (iii) Orbital cellulitis.

(iv) Cavernous sinus thrombosis. (v) Proptosis

(b) Allergic. Acute angioneurotic edema, insect bite, dermatitis medicamentosa, atopic dermitis.

(c) Systemic conditions that produce edema of lids are acute and chronic nephritis, hypoproteinaemia, myxedema and thyrotoxicosis.

Edema may be acute or chronic. It may involve any or all the lids. It may be very mild giving a puffy appearance or may be so pronounced as to obliterate inter palpebral fissure requiring lid retractor to separate the lids. The edema may be transient, manifesting only in a particular time of the day.the child may get up with edema of the lids that pass off within few hours. This is generally due to systemic causes requiring pediatric consultation.

Treatment of edema. Treatment of lid edema is essentially treatment of it’s cause. The local infective causes are treated by antibiotic - local or systemic and hot fomentation. Allergic edema may subside with oral and rarely injectable antihistamine. Steroids are indicated in angioneurotic edema.

2. Ecchymosis of the Lid. The lids are very vascular, hence trauma easily causes extravasations of blood in the lids due to laxity of lid skin. Blood accumulates in the subcutaneous space, giving rise to Ecchymosis. The ecchymotic lid is swollen and bluish green in colour. In infants it may have a red discoloration. As time passes, the colour of lid changes from red to bluish green to black. Hence called Black eye. The causes of black eyes are:

(a) Blunt injury to the lid, orbit, scalp, middle cranial fossa. (b) Blood dyscrasia—Purpura, haemophilia, leukaemia.

(c) Neuroblastoma.

Ecchymosis of the lid may be localised to lid only. It may be associated with sub conjunctival haemorrhage with or without rupture of the globe. In injury to scalp, fracture of orbit or fracture base of skull ecchymosis appears few hours to twenty four hours after the initial injury as it takes some time for the blood to trickle down along the fascia, muscle plane, or along the sheath of the extra ocular muscles. Presence of ecchymosis may be frightening but

not always vision threatening and most of the time disappears without treatment. However ecchymosis of any kind may be just a superficial sign of a deeper malady i.e. fracture base of skull, blood dyscrasia or neuroblastoma or traumatic optic neuropathy.

Treatment of ecchymosis. Echymosis of lid per se does not require any treatment. As a first aid cold compress may reduce the swelling. However after few hours cold compress does not help. Analgesics reduce pain and inflammation. It takes about seven to ten days for simple ecchymosis to disappear.

3. Colour change of the lid. Generally the colour of the lids is similar to that of face and forehead. Some times there may be localised colour changes due to ecchymosis which is temporary and passes off. Birthmarks may last for first few years and gradually disappear. However some of the birthmarks are permanent like naevus, Sturge Weber syndrome and neuro fibromatosis. Hypopigmentation is seen following injury burn and vitiligo.

INFLAMMATION OF THE LID

Inflammatory process may involve :

A.The lid margin (Blepharitis).

B.Glands of the lid margin.

C.Skin and subcutaneous tissues of the lid.

Inflammation of the lid margin is called Blepharitis1,2,3,4. The Causes of blepharitis are bacterial, seborrhic, parasitic, atopic, and allergic.

Blepharitis is broadly divided into squamous, ulcerative (staphylococcal) and parasitic. The former is mostly seborrhic in nature while later is chronic infection by staphylococci or due to its toxins.

The squamous (seborrhic) blepharitis

This is basically disorders of gland of Zeis and is associated with seborrhic dermatitis of eyebrow, scalp and nasolabial fold. The condition is mild. The lid margin has dry scales or greasy material, which are easily removed and on removal there are no ulcers or hemorrhagic spots that are common in ulcerative blepharitis. Seborrhic blepharitis may produce mild chronic conjunctivitis and punctate keratitis in lower part of cornea.

Ulcerative blepharitis

This is more troublesome, produces more complication and is difficult to eradicate. It may be simple staphylococcal or it may be a combination of seborrhoea and staphylococcal infection. This makes it difficult to treat. It generally starts after 3 years of age, involves both the lids on both sides. Involvement of upper lid is more extensive than lower lid. There are yellow crusts at the base of the lashes that may extend over the rounded anterior lid margin and the skin. The cursts are difficult to remove, without wetting them. They are best rubbed off after being moistened by warm water for few minutes. On removal of the crusts, the underlying skin is found to be hyperaemic, and small ulcers are seen. On long run there may be tylosis, madarosis and trichiasis. It is always associated with chronic blepharo

46 PEDIATRIC OPHTHALMOLOGY

conjunctivis and may produce superficial punctate keratitis.

Management of blepharitis is difficult. Treatment of seborrhic blepharitis consists of management of systemic seborrhoea i.e. regular cleaning of the face, use of suitable antidandruff shampoo for the scalp and eyebrow. Local instillation of broad-spectrum antibiotic drops, to prevent secondary infection, for months.

Treatment of ulcerative blepharitis is prolonged. Strict and energetic regime should be followed which consist of:

(i) Removal of crusts by cotton swab soaked in lukewarm water that is applied on the lid margin for 2-3 minutes and the crusts rubbed off with dry cloth.

(ii) Broad Spectrum antibiotic is rubbed on the lid margin. The whole procedure is repeated at least three times a day, same antibiotic is instilled in the conjunctival sac at bed time, steroid with antibiotic ointment may be rubbed on the lid margin—three times a day and gradually tapered off.

If children do not respond to local treatment systemic antibiotic may be required for seven to ten days.

(iii) Personal hygiene. The children should be taught proper hygiene of the face and hands.

(iv) Associated errors of refraction. Should be corrected after proper retinoscopy under cycloplegia.

Complications of ulcerative blepharitis consist of—Tylosis, madarosis, frequent stye, trichiasis, chronic conjunctivis, keratitis and epiphora.

Parasitic blepharitis

Pediculosis and phthiriasis of lids14,15

Common parasitic involvement of the lid margin is pediculosis. There are three types of these arthropods that involve the lid margin. They are pediculosis-corporis, p. capitis and p. pubis. The child gets the infection due to p. capitis from siblings or playmates, while they get the other two types from their infected parents, servants or baby sitters. The lid margin is infested by these parasites which cling to the skin of the lid margin, they lay nits on the shaft of the lashes. Numbers of parasites vary from a few to numerous. They are visible on naked eye when many, but may require magnification when few. The parasites produce chronic itching, redness and secondary infection of the lid margin, conjunctiva and lower cornea.

Treatment. The treatment is mainly treatment of systemic pediculosis in all the contacts.

(i) Local Treatment. In co-operative and older children the parasites may be picked up with epilation forceps or destroyed by direct application of cryo. Anti pediculosis shampoo after proper dilution may be applied to the lid margin. This should precede application of any ophthalmic eye ointment in greasy base. The oily base acts as mechanical repellent for aqueous shampoo which other wise may get into the conjunctiva causing chemical conjunctivitis. 20% fluorescein sodium have been used with good result. The drugs commonly used as shampoo are benzene hexachloride. (Lindane) 1%, premethrine 1%.

(ii) Follow up. Personal hygiene is the key word in management of pediculosis and phthiriasis. The cloths, bedding, combs hairbrushes should be washed in boiling water to avoid

re-infection in carriers and infected children. The contacts should also be treated vigorously and repeatedly for pediculosis.

B. Disorders of glands of lid margin

1. Stye (Hordeolum externum). The stye is an acute staphylococcal infection of gland of Zeis and Moll. They are very common between five years to fifteen years. Boys and girls are equally affected. Tendency of stye runs in families. It is a painful condition that begins as tender red spot on the lid margin. The position of an early stye in the lid can be pin pointed by moving the finger on the lid margin. The patient winces as the exploring finger passes over the stye. There is diffuse swelling of the lid on either side of the stye. Styes situated near the canthi are more painful than in the middle of the lid. Styes of outer canthi are most painful. The upper lid has more glands of Zeis and Moll, hence styes are more frequent and more numerous in upper lid. There may be a single stye that may be cured spontaneously not to appear again. Repeated attacks of styes are very common. There may be multiple crops of styes. Both lids may be affected. Each lid may have single to multiple styes. All lids may be affected at the same times. Associated conjunctivitis is frequent. Preauricular lymph nodes are always enlarged that may be tender. Development of stye after measles is very common. Other predisposing factors are uncorrected errors of refraction that leads to asthenoipa. A child with asthenopia has tendency to rub the eyes with fingers frequently. This introduces infection in the lid margin resulting in repeated styes that disappear with correction of errors of refraction. Other predisposing factors are chronic seborrhic and staphylococcal blepharitis .

Management of Stye

Management of stye consists of (i) Treatment of stye.

(ii) Prevention of recurrence.

(iii) Management of complications.

Treatment of Stye

The treatment is similar to treatment of a boil that consists of local dry hot fomentation, systemic analgesic, anti-inflammatory drug and systemic antibiotic. Local antibiotic eye ointment at bedtime prevents matting of lid margins at night. With above treatment either the stye subsides by evacuation of pus or the lash round which the stye has developed, pus is epilated.

Prevention of recurrence

As error of refraction is one of the important predisposing factors, it should be corrected by appropriate glasses following refaction under cycloplegia. Stye itself can induce slight astigmation hence refraction should be under taken only when the child is free from stye.

Proper lid hygiene should be maintained. Cleaning the lid margins and application of broad spectrum antibiotic eye ointment at night for at least two months after the stye has subsided.

In chronic and recurrent stye doxycyclin 100mg daily for ten days gives relief. However doxycyclin is not preferred in children under eight years as it may cause permanent staining of the teeth. In such children long acting sulpha or erythromycin in consultation with pediatrician should be given.