Abnormalities of the Lids

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Chapter 616 Abnormalities of the Lids

Scott E. Olitsky, Denise Hug, Laura S. Plummer, Merrill Stass-Isern

Ptosis

In blepharoptosis, the upper eyelid droops below its normal level. Congenital ptosis is usually a result of a localized dystrophy of the levator muscle in which the striated muscle fibers are replaced with fibrous tissue. The condition may be unilateral or bilateral and can be transmitted as a dominant trait.

Parents often comment that the eye looks smaller because of the drooping eyelid. The lid crease is decreased or absent where the levator muscle would normally insert below the skin surface. Because the levator is replaced by fibrous tissue, the lid does not move downward fully in downgaze (lid lag). If the ptosis is severe, affected children often attempt to raise the lid by lifting their brow or adapting a chin-up head posture to maintain binocular vision. Marcus Gunn jaw-winking ptosis accounts for 5% of ptosis in children. In this syndrome, an abnormal synkinesis exists between the 5th and 3rd cranial nerves; this causes the eyelid to elevate with movement of the jaw. The wink is produced by chewing or sucking and may be more noticeable than the ptosis itself.

Although ptosis in children is often an isolated finding, it may occur in association with other ocular or systemic disorders. Systemic disorders include myasthenia gravis, muscular dystrophy, and botulism. Ocular disorders include mechanical ptosis secondary to lid tumors, blepharophimosis syndrome, congenital fibrosis syndrome, combined levator/superior rectus maldevelopment, and congenital or acquired 3rd nerve palsy. A small degree of ptosis is seen in Horner syndrome (Chapter 614). A complete ophthalmic and systemic examination is therefore important in the evaluation of a child with ptosis.

Amblyopia may occur in children with ptosis. The amblyopia may be secondary to the lid’s covering the visual axis (deprivation) or induced astigmatism (anisometropia). When amblyopia occurs, it should generally be treated before treating the ptosis.

Treatment of ptosis in a child is indicated for elimination of an abnormal head posture, improvement in the visual field, prevention of amblyopia, and restoration of a normal eyelid appearance. The timing of surgery depends on the degree of ptosis, its cosmetic and functional severity, the presence or absence of compensatory posturing, the wishes of the parents, and the discretion of the surgeon. Surgical treatment is determined by the amount of levator function that is present. A levator resection may be used in children with moderate to good function. In patients with poor or absent function, a frontalis suspension procedure may be necessary. This technique requires that a suspension material be placed between the frontalis muscle and the tarsus of the eyelid. It allows patients to use their brow and frontalis muscle more effectively to raise their eyelid. Amblyopia remains a concern even after surgical correction and should be monitored closely.

Epicanthal Folds

These vertical or oblique folds of skin extend on either side of the bridge of the nose from the brow or lid area, covering the inner canthal region. They are present to some degree in most young children and become less apparent with age. The folds may be sufficiently broad to cover the medial aspect of the eye, making the eyes appear crossed (pseudoesotropia). Epicanthal folds are a common feature of many syndromes, including chromosomal aberrations (trisomies) and disorders of single genes.

Lagophthalmos

This is a condition in which complete closure of the lids over the globe is difficult or impossible. It may be paralytic because of a facial palsy involving the orbicularis muscle, or spastic, as in thyrotoxicosis. It may be structural when retraction or shortening of the lids results from scarring or atrophy consequent to injury (burns) or disease. For example, children with various craniosynostosis syndromes can have problematic lagophthalmos. Infants with collodion membrane may have temporary lagophthalmos caused by the restrictive effect of the membrane on the lids. Lagophthalmos may accompany proptosis or buphthalmos (enlarged cornea due to elevated intraocular pressure) when the lids, although normal, cannot effectively cover the enlarged or protuberant eye. A degree of physiologic lagophthalmos may occur normally during sleep, but functional lagophthalmos in an unconscious or debilitated patient can be a problem.

In patients with lagophthalmos, exposure of the eye may lead to drying, infection, corneal ulceration, or perforation of the cornea; the result may be loss of vision, even loss of the eye. In lagophthalmos, protection of the eye by artificial tear preparations, ophthalmic ointment, or moisture chambers is essential. Gauze pads are to be avoided because the gauze may abrade the cornea. In some cases, surgical closure of the lids (tarsorrhaphy) may be necessary for long-term protection of the eye.

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