Pediatric Oculoplastic Surgery

At Eyesthetica, we see and treat children as well.  We are a tertiary-level, referral based center, and therefore we treat pediatric oculoplastic issues as common as congenital nasolacrimal duct obstruction (CNLDO) and congenital ptosis to more complex issues such as congenital microphthalmia and craniofacial anomalies.

Children with CNLDO have symptoms of tearing and mattering. CNLDO is a very common condition where the extreme end of the nasolacrimal duct fails to complete its canalization. A fluorescein dye disappearance test is the single most useful test. Be sure to exclude the diagnosis of congenital glaucoma in the tearing infant by evaluating corneal edema and diameter. CNLDO spontaneously resolves in 90% of infants during the first year of life. Digital massage to the skin over the nasal lacrimal sac may speed up the resolution. If not spontaneously resolved after the age of 1, a small procedure called lacrimal probing can be done under general anesthesia and has over 90% success rate. Nasolacrimal intubation with silicone tubes can also be used to help with patency. Children who continue to have epiphora after probing or probing and silicone intubation will need dacryocystorhinostomy, where a new lacrimal drainage system is created, thus bypassing the obstruction.

Congenital blepharoptosis is caused by dysgenesis of the levator palpebrae superioris. Adipose and fibrous tissue in the levator cause a deficiency of the muscle to contract sufficiently to elevate the eyelid to its normal level and also to relax sufficiently to allow full depression of the upper eyelid on downgaze. This clinically results in ptosis in primary gaze, decrease of levator function, lid lag in downgaze, and occasionally lagophthalmos. The eyelid crease is usually shallow or absent. Children with congenital ptosis are at risk for developing amblyopia due to high astigmatism (more commonly) or occlusion by the ptotic eyelid (more rarely).  Therefore, evaluation for amblyopia is critical, along with cycloplegic streak retinoscopy with spectacle correction, and eye patching if necessary.  If the child has amblyopia, or is at high risk of developing amblyopia, surgical correction for congenital ptosis is performed right away.  If the child is not at risk of amblyopia, then surgical correction is usually deferred until the child is about to enter kindergarten.  This timing serves 2 purposes:  the child is better at following directions to allow us to obtain proper measurements for the ideal operation, yet the repair is prior to school interaction to try to reduce negative psychosocial impact on the child, such as self-consciousness and teasing.  Surgical approach for congenital ptosis is based on the amount of levator function (the excursion of eyelid margin from downgaze to upgaze with the brow fixated manually). When levator function is greater than 4 mm, levator resection is the standard surgical approach.  A levator resection involves cutting out a portion of the levator and reattaching it to the tarsus, thus raising the eyelid.  When levator function is 4 mm or less, frontalis suspension/sling is the surgical approach, where material such as silicone or fascia lata, is sewn onto the tarsus, tunneled deep to the orbital septum and brow and then sewn to the frontalis muscle.  The child then can open his eyelids by raising his eyebrow, since the eyelid is suspended from the brow.

We are able to perform a levator resection surgery through a small incision of 12 to 16 mm instead of the standard incision of 25 mm and have lectured and presented our approach at both national and local meetings.

Eyesthetica is the largest private group in the greater Los Angeles area, whose practice is dedicated solely to oculofacial plastic surgery specializing in cosmetic surgery, eyelid reconstruction, lacrimal and orbital surgery.  We have opened a new office in Torrance to better serve you and your patients.

Eyesthetica                                                                                   Ophthalmic Plastic & Reconstructive Surgery

Oculofacial and Cosmetic Surgery Associates                                                   Orbital and Lacrimal Surgery

Steven C. Dresner, M.D., Michael A. Burnstine, M.D., Melanie Ho Erb, M.D.                               Cosmetic Surgery

Santa Monica          Pasadena               Torrance               Downtown Los Angeles                                                               

310-453-1763         626-564-0004       310-530-9482       213-482-3467                                                                               www.Eyesthetica.com