Pediatric Oculoplastic Care

Congenital ptosis is drooping of one or both eyelids that occurs during development and is often noticed by parents at birth or in early childhood.  This happens because one of the muscles that lifts the eyelid does not develop normally.  It is often less “stretchy” than a normal muscle, resulting in the drooping eyelid and poor movement of the eyelid.

Parents may notice:

• Drooping of the eyelids
• A “chin up” position so the child can see better
• Uneven appearance of the eyes
• Poor closure of the eyelid when the child is sleeping

Often, mild drooping of the eyelid can be monitored until the child grows up or is bothered by the appearance. Regular thorough eye exams are important to ensure that the vision is not being affected.

If the drooping is more severe, surgery may be required to preserve and restore vision in the eye.  Early diagnosis and treatment can be vision-saving.  Surgery is typically well tolerated in kids.  The type of surgery performed depends on how much function the muscle has.  Sometimes the natural muscle may be tightened, but sometimes the function of the muscle is not adequate, and a different surgical technique may be used.  Dr. Stewart will discuss options with you based on the severity of the drooping and muscle function.

An orbital dermoid is a benign (non-cancerous) cyst that forms near the eye, usually present at birth. It is made up of skin cells and other tissue trapped during early development.   These cysts typically form near the outer corner of the eyebrow around the eye socket (orbit). They can vary in size and are usually painless and slow growing.  Most dermoids don’t affect vision unless they grow large or press on the eye.

Parents may notice:

• A soft or firm lump near the eyebrow or around the eye
• No pain with touching of the bump
• Slow growth from a few months old

Treatment usually involves surgical removal, especially if the dermoid is growing, causing symptoms, or affecting appearance.  Surgery is typically recommended around age 1, when the child begins to be more mobile.  If the cyst were to rupture, it can cause significant inflammation in the eyelid, which can be painful for the child.   Once removed, orbital dermoids typically do not come back.   The incision is tucked within the natural crease of the eyelid, so no visible scar remains.  Children recover quickly and usually have excellent long-term outcomes.

Craniofacial defects are conditions where a baby is born with abnormalities in the structure of the head, face, or skull. These can range from mild to complex and may affect appearance, breathing, vision, hearing, or brain development.  It is important to receive multi-disciplinary care for craniofacial defects, which often includes pediatric plastic surgeons, neurosurgeons and oculoplastic surgeons.

Common Types Include:

• Cleft lip and palate: Openings in the upper lip and/or roof of the mouth
• Craniosynostosis: Early closing of the skull bones, which can affect head shape and brain growth
• Hemifacial microsomia: Underdevelopment of one side of the face
• Facial clefts or syndromes (e.g., Treacher Collins, Apert syndrome): More complex conditions that may involve the eyes, ears, jaw, and skull

Signs and Symptoms:

• Unusual head or facial shape
• Gaps or openings in the lip or mouth
• Breathing, eating, or vision problems
• Developmental delays (in more complex cases)

A chalazion or stye forms when one of the small oil glands of the eyelid becomes blocked.  The oil that is produced in the glands backs up as it cannot be released, and the result is a lump on the eyelid.  The bump may be skin colored or red, and it is often sore for the first few days.  This is a result of inflammation within the eyelid.  Most chalazia or styes are not infections.

Parents might notice:

• A firm, round lump on the eyelid
• Mild redness or swelling of the eyelids
• Possible blurred vision if the lump presses on the eye
• Tenderness or irritation

Treatment:

Most chalazia improve on their own or with simple home care, including:

• Warm compresses to help unblock the gland 4-6 times daily
• Gentle eyelid massage after a warm compress
• Keeping the eyelid clean

When a chalazion becomes increasingly painful, or does not resolve within a few weeks, further treatment is often necessary.  Dr. Stewart may suggest further treatment options including:

• Oral medications including oral antibiotics
• Medicated eye drops or ointments
• Surgical incision and drainage

Preventing Chalazion

There are some simple steps you can take to prevent future chalazia:

• Maintain good eyelid hygiene: Regularly clean the eyelids
• Avoid rubbing the eyes: This can irritate the glands and increase the chance of blockage.
• Use warm compresses: Applying warm compresses periodically can help keep oil glands open and functioning properly.
• Take fish oil gummy vitamins: this may help thin the oil secretions and decrease the likelihood of more chalazia.
• Manage underlying conditions: If you have blepharitis or other eyelid inflammations, Dr. Stewart will recommend a treatment regimen specific to your conditions to minimize your risk of recurrent chalazia.

A congenital nasolacrimal duct obstruction is a common condition in babies where the tear duct is blocked at birth.  This is typically caused by a small membrane that does not open properly at the bottom of the tear drainage system.

Parents may notice:

• Tearing even when the baby is not crying
• Crusting or discharge around one eye more than the other
• Mild redness of the eye or skin below the eye

Most cases are mild and resolve on their own within 1 year of life.  A gentle massage with warm compresses around the tear drainage system (Crigler massage) may help to open the duct and improve drainage.   If your child gets infections from the blockage, antibiotic ointment or drops may be suggested.

If the blockage does not resolve by 1 year, a probing of the tear drain may be suggested. The success rate of a simple probing is very high and there is no pain and minimal recovery following a probing procedure.

Rarely, the blockage does not improve with a simple probing.  At that point, Dr. Stewart may recommend other surgical treatments based on your child’s anatomy and age including:

• Probing with stent placement: The soft silicone stent placed within the tear drain forces the drain to stay open as the body heals and has a higher success rate
• Balloon dacryoplasty with stent: If the tear drainage pathway is quite narrow, a balloon may be placed within it and inflated to stretch out the natural duct. A stent then keeps the tissue open as the body heals
• Dacryocystorhinostomy: This procedure re-routes the tear drainage system. Typically this procedure is recommended after the age of 8-10 when the bones of the face are more mature except in the case of severe infections.

Orbital tumors are abnormal growths that develop in or around the eye socket (orbit) in children. They can be benign (non-cancerous) or malignant (cancerous), and may affect vision, eye movement, or appearance.  Most orbital tumors in children are benign and treatable. With early diagnosis and appropriate care, outcomes are often very good—even for some malignant tumors.

Parents may notice:

• Bulging of one eye (proptosis)
• Swelling or redness around the eye
• Changes in vision or eye movement
• Drooping eyelid
• A visible lump or mass

Common Types Include:

• Capillary hemangioma: A common benign tumor in infants, often called a “strawberry mark.”
• Dermoid cyst: A benign, slow-growing cyst often found near the eyebrow.
• Lymphangioma: A benign, fluid-filled tumor that can suddenly enlarge, especially with illness, and cause eye swelling.
• Rhabdomyosarcoma: A rare but serious cancerous tumor that grows quickly and needs urgent treatment.

If there is concern for an orbital tumor, Dr. Stewart will order imaging studies and may suggest a biopsy or removal based on the likely diagnosis.  If you notice unusual swelling, bulging, or changes in your child’s eye, see Dr. Stewart as soon as possible. Early evaluation is key to the best possible outcome.