Punctal Atresia As a Clinical Indicator of Systemic Genetic Anomalies

BACKGROUND

Punctal atresia or agenesis (PA) is a rare congenital anomaly characterized by the absence or closure of the tear duct puncta, potentially linked to systemic genetic anomalies. The necessity of a genetic workup based solely on the presence of PA remains uncertain. This study investigates a cohort of PA patients, examining the prevalence and types of associated syndromes.

METHODS

A retrospective medical records review of all patients diagnosed with PA at the Children's Hospital of Philadelphia between 2009-2023 was conducted, analyzing medical histories and genetic testing results. Primary outcomes included the prevalence of systemic syndromes, while secondary outcomes focused on the variety of associated syndromes.

RESULTS

Forty-four patients were included, of which 31 were male (70%) with a mean ± SD age 3.3 ± 3.3 years. Overall, 87 puncta in the study cohort were affected, and 26 cases (59%) were bilateral. Systemic abnormalities or genetic syndromes were identified in 19 patients (43%), with the most common being Ectodermal Dysplasia and Down syndrome. Additional rare syndromes were demonstrated. No significant association was found between systemic abnormalities and gender, bilaterality, or the number of puncta involved.

CONCLUSIONS

A high incidence of systemic syndromes (43%) was observed in the study cohort. In individuals with PA who also exhibit extraocular disease, systemic evaluation and genetic workup should be considered. Syndromic diagnoses identified in our cohort also include: Branchio-oto-renal syndrome, 22q11.2 deletion syndrome, 1q21.1 microdeletion syndrome, NF1, monosomy 4q and trisomy 6q, which represent novel associations. The lack of correlation between PA's phenotypic severity and systemic abnormalities highlights the need to obtain a comprehensive medical history and consider a systemic workup in PA patients.

Cryptophthalmos: associated syndromes and genetic disorders

PURPOSE

Cryptophthalmos is a rare congenital condition caused by anomalous eyelid development where the eyelid folds do not develop or fail to separate. Cryptophthalmos can be unilateral or bilateral and can occur in isolation or as part of an underlying syndrome. We aim to identify genetic syndromes associated with cryptophthalmos to facilitate genetic diagnosis.

METHODS

We performed a retrospective medical record review of all patients diagnosed with cryptophthalmos followed at a single center between 2000 and 2020. The analysis included medical history, clinical examination findings, and genetic testing results.

RESULTS

Thirteen patients were included, 10 (77%) males, mean age of 2.4 years. Eight (61%) had bilateral cryptophthalmos, and 4 (31%) had complete cryptophthalmos. Associated ocular abnormalities included corneal opacities (13/13, 100%), upper eyelid colobomas (12/13, 92%), and microphthalmia/clinical anophthalmia (3/13, 23%). All cases of complete cryptophthalmos had bilateral disease. An underlying clinical or molecular diagnosis was identified in 10/13 (77%) cases, including Fraser syndrome (n = 5), amniotic band syndrome (n = 1), FREM1-related disease (n = 1), Goldenhar versus Schimmelpenning syndrome (n = 1), MOTA syndrome (n = 1), and CELSR2-related disease (n = 1).

CONCLUSION

This is the first report of a possible association between cryptophthalmos and biallelic CELSR2 variants. Children with cryptophthalmos, especially those with extra-ocular involvement, should be referred for comprehensive genetic evaluation.

Outcome of Primary Monocanalicular Stent Placement in Pediatric Down Syndrome Patients with Congenital Nasolacrimal Obstruction

PURPOSE

Congenital Nasolacrimal duct obstruction (CNLDO) is a relatively common problem in children with Down syndrome (DS). Probing and irrigation (PI) with monocanalicular stent intubation may be less successful than in non-DS patients, thus raising some concerns regarding the preferred treatment in this population. We aimed to analyze the surgical outcome of PI along with monocanalicular stent intubation in children with DS compared with non-DS patients.

METHODS

Retrospective cohort study. Thirty-five eyes of 19 children with DS and 1,472 eyes of 1,001 children without DS underwent PI-monocanalicular stent intubation as a primary treatment for CNLDO. All patients were operated on by a single surgeon at the Children's Hospital of Philadelphia between 2009 and 2020. The main outcome measure was a surgical success, defined as the resolution of symptoms after surgery.

RESULTS

A total of 1,020 patients were included, 48% females; mean age of 1.9 ± 1.4 years. The mean follow-up time was 35.0 months. The DS patients group consisted of 19 patients. Higher rates of right nasolacrimal duct obstruction and bilateral obstructions were observed in the DS group (100% vs. 73.2%; p = 0.006, and 84.2% vs. 46.8%; p = 0.001, respectively). Patients with DS had a lower success rate (57.1% vs. 92.4%; p < 0 .0001). The median time to failure was 3.1 months in the DS group, and 5.2 months in the group of patients without DS. The hazard ratio comparing DS to the no-DS outcome was 6.6 (95% CI: 3.2-13.7; p < 0.001).

CONCLUSIONS

CNLDO in DS is more likely to be bilateral and less likely to resolve after primary monocanalicular stent placement.

The surgical management and outcomes of kissing nevi of the eyelids

PURPOSE

To describe the clinical characteristics, surgical technique, and outcomes in patients with kissing nevi who underwent surgical management in two tertiary referral centers.

METHODS

Medical chart review was conducted for all patients who underwent surgical repair in Moorfields Eye Hospital and The Children's Hospital of Philadelphia. Demographics, medical history, lesion characteristics, surgical intervention, and outcomes were collected. Main outcome measures were surgical interventions as well as functional and cosmetic outcomes.

RESULTS

Thirteen patients were included. Mean age at presentation was 23.46 years (±19.35,4-61), and the mean number of surgeries per patients was 1.9 (±1.3,1-5). Initial procedure included incisional biopsy in three cases (23%) and complete excision and reconstruction in 10 cases (77%). Surgery involved the upper and lower anterior lamella in all cases, the upper posterior lamella in 4 patients (31%), and the lower posterior lamella in 2 patients (15%). Local flaps were utilized in 3 cases and grafts in 5 cases. Complications included: trichiasis (n = 2, 15%), lower eyelid ectropion (n = 2, 15%), mild ptosis (n = 1, 8%), and upper/lower punctal ectropion (n = 1, 8%). Twelve patients (92%) were satisfied with the final functional and cosmetic outcome. No recurrence or malignant transformation were observed in any patient.

CONCLUSION

The surgical management of kissing nevi can be challenging, and commonly includes the use of local flaps or grafts, often requiring multiple interventions. The approach should be based on lesion size and location, proximity and involvement of key anatomical landmarks, as well as individual facial characteristics. Surgical management has a favorable functional and cosmetic outcome in the majority of patients.

Outcome of silicone sling frontalis suspension in children with simple congenital and complex ptosis

OBJECTIVE

To compare the outcome of silicone sling frontalis suspension (FS) surgery in children with simple congenital ptosis and children with complex ptosis.

DESIGN

A retrospective cohort study.

PARTICIPANTS

All pediatric patients who underwent silicone sling FS surgery between 2009 and 2020 at a single centre.

METHODS

Patients were divided based on etiology into simple congenital ptosis and complex congenital ptosis. Pre- and postoperative margin-to-reflex distance (MRD₁) measurements were determined from clinical photographs. Main outcome measures were assessed as differences in improvement in eyelid height and reoperation rate between the groups.

RESULTS

Two-hundred and eight children were included: 139 simple and 69 complex cases, with 83 females (40%). Mean (±SD) age at intervention was 1.9 ± 2.9 years. Complex cases included blepharophimosis epicanthus inversus syndrome (n = 35), Marcus Gunn jaw-winking syndrome (n = 12), oculomotor palsy (n = 8), congenital fibrosis of extraocular muscles (n = 3), chronic progressive external ophthalmoplegia (n = 3), and others. Mean MRD₁ improved by an average of 1.6 mm in both groups. Repeat ptosis correction was performed in 50 of 171 patients (29%) without a history of failed ptosis procedures, and this rate was similar between simple and complex cases. Children under 3 years of age had higher rates of repeat ptosis repair than older children (n = 59 of 175 [34%] vs n = 5 of 33 [15%]; p = 0.03, χ² test).

CONCLUSIONS

Silicone sling FS has a favourable outcome in 70% of pediatric patients. Preoperative and final MRD₁ and reoperation rates were similar between both groups, suggesting that despite the higher complexity in atypical cases, the outcome is similar.

Management of congenital nasolacrimal duct obstruction in down syndrome

BACKGROUND

Congenital nasolacrimal duct obstruction (CNLDO) is common in Down Syndrome (DS), and more difficult to treat. Our purpose was to describe the management of CNLDO in paediatric patients with DS.

METHODS

Retrospective cohort study. Medical chart review of all DS patients diagnosed with CNLDO at the Division of Ophthalmology at the Children's Hospital of Philadelphia during a 12-year period (2009-2020). Main outcome measures included: Surgical interventions, primary probing outcome, rate of dacryocystorhinostomy (DCR) and/or conjunctivodacryocystorhinostomy (CDCR), and overall success.

RESULTS

126 patients (236 eyes) were included, mean age of 1.8 ± 2.1 years (range 0.1-11.3 y), 110 (87%) had bilateral CNLDO. Mean follow-up time was 41 months. 84 patients (67%) underwent at least one surgical intervention; the mean number of surgical interventions in this group was 1.8 ± 1.4 per patient (range, 1-6). The most common primary intervention was probing (n = 74, 88%), mostly (n = 57, 68%) with monocanalicular silicone intubation. Probing with silicone intubation had a higher success rate compared to probing alone (P = 0.002). Twenty (24% of 84) patients underwent DCR/CDCR during the follow-up period. Complete resolution was achieved in 123 patients (98%).

CONCLUSIONS

CNLDO in Down syndrome is associated with high rates of bilateral obstructions and with less favourable surgical outcomes. Many patients ultimately require a more robust surgical intervention such as DCR or CDCR. The use of monocanalicular stent in initial probing was associated with a higher success rate, and would appear to be appropriate in all CNLDO-DS cases.

Silicone sling frontalis suspension for congenital ptosis: Outcome of 174 consecutive cases

BACKGROUND

Frontalis suspension (FS) is the treatment of choice in congenital ptosis with poor levator function. We report the surgical outcome of FS using a double triangle configuration of silicone slings in children.

METHODS

A retrospective cohort study of all paediatric patients with simple myogenic congenital ptosis repaired with FS over a 12-year period (2009-2020). Each silicone sling was secured by simple knots. Pre- and post-operative margin reflex distance (MRD₁ ) measurements were determined from clinical photographs using ImageJ Software. Main outcome measures were improvement in eyelid height, eyelid asymmetry, reoperation rate and timing.

RESULTS

One hundred and thirty nine patients (174 eyes) were included, with 35 (25%) having bilateral surgery. Mean (±SD) age was 1.4 ± 1.9 years. Mean follow up time was 32 ± 20.5 months. Sixteen patients (11%) had a history of previous ptosis repair surgery. Mean MRD₁ improved by an average of 1.5 mm. The final MRD₁ in the group of patients who did not have a second procedure was a mean of 2.1 mm. The MRD₁ difference between both eyes in all unilateral cases improved from 2.5 mm preoperatively to 1.2 mm at final visit (p < 0.001). In the 123 cases without a history of previous ptosis surgery, repeat ptosis repair was performed in 37 (30%) patients, 34.9 ± 19.9 months after the initial procedure. Overall, repeat repair was performed in 47 patients (34%).

CONCLUSIONS

Double triangle silicone sling frontalis suspension has a favourable outcome in two-thirds of paediatric patients with simple myogenic congenital ptosis. Failed cases can be addressed with a second repair, using either autogenous fascia lata or a second silicone sling.

Recovery of Vision after Optic Nerve Sheath Fenestration in Children and Adolescents with Elevated Intracranial Pressure

PURPOSE

To evaluate the effect of optic nerve sheath fenestration (ONSF) on the recovery of visual function in pediatric patients with optic disc swelling owing to increased intracranial pressure.

DESIGN

Retrospective case series.

METHODS

Medical chart review of all pediatric patients who underwent ONSF between 2009 and 2020 at the Children's Hospital of Philadelphia. Visual function was assessed at pre and postoperative visits. The main outcome measures were visual acuity, color vision, extraocular motility, visual field mean deviation, retinal nerve fiber layer thickness measured by optical coherence tomography.

RESULTS

Fourteen pediatric patients (10 females; mean ± SD age of 14 ± 2.6 years; range, 8.5-17.5 years) were included. Five patients underwent bilateral surgeries. Ten patients were diagnosed with idiopathic intracranial hypertension. Of the 10 idiopathic intracranial hypertension patients, 3 had a previous history of weight gain and 2 of systemic steroid treatment; these can be referred to as pseudotumor cerebri. The mean ± SD follow-up length was 16.4 ± 12.3 months. VA improved from 20/138 to 20/68 in the operated eye (P = .0003) and from 20/78 to 20/32 in the nonoperated eye (P = .02). Color vision improved in the operated eye (P = .04), extraocular motility improved in the operated and nonoperated eye (P = .002 and P = .04 respectively). Visual field mean deviation improved in the operated (-23.4 dB to -11.5 dB, P < .0001) and nonoperated eye (-19.8 dB to -6.8 dB, P = .02). Retinal nerve fiber layer thickness improved in the operated eye (349.1 to 66.2 µm; P < .0001). The postoperative improvement was observed as early as the postoperative day 1.

CONCLUSIONS

ONSF produces a rapid and persistent vision improvement in both the operated eye and the nonoperated eye. In children and young adults with papilledema and elevated intracranial pressure causing vision loss that is severe at presentation or refractory to standard medical management, ONSF should be considered.

Management of Pediatric Acute Dacryocystitis

PURPOSE

To analyze the clinical presentation, course, and management in a large cohort of pediatric acute dacryocystitis subjects and to examine whether hospitalization and urgent surgical intervention are indeed mandatory.

METHODS

A retrospective analysis of all pediatric subjects diagnosed with dacryocystitis at the Children's Hospital of Philadelphia over a 12-year period (2009-2020).

RESULTS

One-hundred sixty-nine pediatric acute dacryocystitis patients were included in this study. Management included admission in 117 cases (69%). Sixty-eight patients (40%) were treated medically with no surgical intervention, 75 cases (44%) required urgent surgical intervention, and 26 additional cases (15%) required surgery due to persistent tearing symptoms after medical management. The urgent procedures included most commonly: 1) endonasal examination and microdebridement of intranasal cysts in 26 cases (35%); 2) probing and irrigation without examination and microdebridement, with or without stent intubation, in 30 cases (40%); and 3) dacryocystorhinostomy (13 endonasal and 4 external) in 17 cases (23%).

CONCLUSIONS

Management of pediatric acute dacryocystitis should be tailored individually for each case. Hospital admission and early surgical intervention are not mandatory, as 31% of cases resolved without admission, and 56% without early surgical intervention. Although a specific age cutoff is not plausible, hospital admission for younger patients is more commonly advocated. When surgical intervention is indicated, endonasal examination and microdebridement of any associated intranasal cyst and probing with possible stenting are the initial procedures of choice. Dacryocystorhinostomy is reserved for more complex obstructions. Although pediatric acute dacryocystitis is an infection with serious potential problems, when managed appropriately, complications are rare.

Ocular manifestations of ectodermal dysplasia

Purpose

The ectodermal dysplasias (EDs) constitute a group of disorders characterized by abnormalities in two or more ectodermal derivatives, including skin, hair, teeth, and sweat glands. The purpose of the current study was to evaluate ocular manifestations in pediatric patients with ED.

Methods

Retrospective case series including consecutive ED subjects who were treated in the ophthalmology department at the Children’s Hospital of Philadelphia over a 12-year period (2009–2020). Main Outcome Measures were ocular and ocular adnexal abnormalities.

Results

Thirty subjects were included: 20 males (67%), mean age of 4.5 years (range 0.3–18). Patients with different subtypes were included, with the hypohidrotic ED and ectrodactyly-ectodermal dysplasia-clefting variants being most prevalent. Most common findings were: lacrimal drainage obstruction in 12 (40%) including punctal agenesis in 10 (33%), refractive errors in 13 (43%) and amblyopia in 6 (20%). A new finding of eyelid ptosis or eyelash ptosis was demonstrated in 11 subjects (37%), mostly associated with TP63 or EDA1 genes variants.

Conclusion

Ectodermal dysplasias are associated with various ocular pathologies and amblyopia in the pediatric population. We report a possible genetic association between lash ptosis and EDA1 gene, and eyelid ptosis and TP63 or EDA1 genes variants.

"Blepharophimosis-plus" syndromes: Frequency of systemic genetic disorders that also include blepharophimosis

BACKGROUND

To determine the frequency of isolated blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) versus systemic genetic disorders in patients presenting with blepharophimosis.

METHODS

Retrospective clinical records review. The records of all patients with blepharophimosis seen in the Division of Ophthalmology at the Children's Hospital of Philadelphia during a 12-year-period (2009-2020) were reviewed for medical history, clinical examination findings and results of genetic analyses.

RESULTS

The 135 patients identified with blepharophimosis included 72 females (53%) and 63 males (47%) whose mean ± standard deviation age at first visit was 3.5 ± 6.4 years (range 0-39.8 years). Sixty-seven of the patients (50%) had undergone genetic testing for FOXL2 gene mutation. Fifty-four (81%) harboured FOXL2 gene mutations and 13 (19%) did not. Altogether, 126 patients (93%) had a final diagnosis of isolated BPES. The remaining nine (7%) had syndromic diagnoses ("blepharophimosis-plus"), including Dubowitz syndrome (n = 2), Ohdo syndrome (n = 1), 22q11.2 duplication (n = 1) and 3q22 deletion (n = 2). Three patients with multiple congenital anomalies remain undiagnosed.

CONCLUSIONS

Blepharophimosis is an eyelid feature occurring most commonly in isolation due to FOXL2 gene mutation, but can also be a harbinger of multisystem disease not exclusive to isolated BPES, as observed in 7% of cases in this series. The ophthalmologist is often the first to recognise these unique features, and must consider and rule out non-BPES syndromes before establishing a diagnosed classic BPES. A comprehensive genetic evaluation is, therefore, indicated in all cases.

Preloaded Monoka (Lacrijet) and congenital nasolacrimal duct obstruction: Initial results

STUDY OBJECTIVE

To study the performance of a pre-loaded Monoka stent in the management of congenital nasolacrimal duct obstruction (CNLDO).

STUDY DESIGN

Non-randomized study of consecutive cases.

MATERIALS AND METHODS

A preloaded classic Monoka silicone stent contained entirely inside its introducer (Lacrijet) was used to treat a consecutive series of subjects with CNLDO over an 11-month period (May 2019-March 2020). Only subjects with chronic symptomatic CNLDO were included. Subjects with intermittent tearing, canalicular pathology, trisomy 21, facial cleft, or history of lacrimal surgery were excluded. Intraoperative findings were recorded, including the degree and location of the nasolacrimal obstruction, successful metal to metal contact with the probe, any difficulties encountered by the Lacrijet device itself, procedure duration, tolerability of the fixation punctal plug, and finally, inspection of the stent after withdrawal of the inserter. Functional success was defined as disappearance of all symptoms of epiphora.

RESULTS

A total of 45 preloaded Monoka Lacrijet stents (Lcj) were placed consecutively in 38 children. The mean age was 27.9 months (12-78 months). The mean procedural duration was 2.8minutes (range: 1-10min). The overall success with disappearance of all symptoms of epiphora was 88.8% (40/45). Surgery in cases of simple mucosal stenosis was successful in 92.2% (35/38) of cases, with a mean follow-up time of 7.9 months (range: 1 to 12 months). The duration of stent intubation was for this group was 32 days (range: 1-103). The surgical outcomes for the other 7 cases with more complex intraoperative findings are summarized in the publication. All withdrawn probes were intact.

CONCLUSIONS

The Lacrijet stent system is a simple and reliable pushed intubation device for CNLDO in appropriately selected cases where bony stenosis of the canal is minimal.

Ocular manifestations and surgical interventions in pediatric patients with Koolen-de-Vries syndrome

Background: Koolen-de Vries syndrome (KdVS) (OMIM #610443) or 17q21.31 microdeletion syndrome, is a rare genetic disorder characterized by developmental and speech delay, intellectual disability, epilepsy, hypotonia, characteristic facial features, and congenital malformations of multiple organs.The purpose of the current study was to describe ocular manifestations and surgical interventions in six KdVS pediatric patients, and to review the ocular associations of this condition.Materials and Methods: A retrospective review of consecutive KdVS subjects who were treated in the ophthalmology department at The Children's Hospital of Philadelphia over a 12-year period (2009-2020) was performed. Main Outcome Measures were ocular and ocular adnexal abnormalities, and ophthalmic surgical interventions.Results: Six patients were included (4 females (67%), mean age of 3.1 years (range 0.1 to 8.1 years)). The most common ocular findings were strabismus (n = 3/6, 50%), ptosis (n = 3/6, 50%), and hyperopia (n = 3/6, 50%). Two patients had amblyopia. Four patients required surgical intervention, including strabismus repair (n = 3), and bilateral levator resection and medial canthopexies (n = 1).Conclusions: KdVS is associated with various ocular and ocular adnexal abnormalities. Most commonly ptosis, strabismus and hyperopia. Most cases required surgical intervention, most commonly strabismus repair. These findings mandate early ophthalmic evaluation with regular follow-up in this unique group of children.

Intralacrimal migration of Masterka® stents

BACKGROUND

Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka^® is a recent version of Monoka^®, which may lead to the same surgical complications, such as intralacrimal migration.

SUBJECTS AND METHODS

The medical records of two patients surgically treated with the Masterka^® probe for nasolacrimal duct obstruction, who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka^® was retrieved through a canalicular approach. In both cases, infants had no further tearing.

DISCUSSION

The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora, is discussed.

CONCLUSION

Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

Orbital/Periorbital Plexiform Neurofibromas in Children with Neurofibromatosis Type 1: Multidisciplinary Recommendations for Care

TOPIC

Children and adults with neurofibromatosis type 1 (NF1), a common autosomal dominant condition, manifest a variety of ophthalmologic conditions. Plexiform neurofibromas (PNs) involving the eyelid, orbit, periorbital, and facial structures (orbital-periorbital plexiform neurofibroma [OPPN]) can result in significant visual loss in children. Equally important, OPPNs can cause significant alteration in physical appearance secondary to proptosis, ptosis, and facial disfigurement, leading to social embarrassment and decreased self-esteem.

CLINICAL RELEVANCE

Although NF1 is a relatively common disease in which routine ophthalmologic examinations are required, no formal recommendations for clinical care of children with OPPNs exist. Although medical and surgical interventions have been reported, there are no agreed-on criteria for when OPPNs require therapy and which treatment produces the best outcome.

METHODS

Because a multidisciplinary team of specialists (oculofacial plastics, pediatric ophthalmology, neuro-ophthalmology, medical genetics, and neuro-oncology) direct management decisions, the absence of a uniform outcome measure that represents visual or aesthetic sequelae complicates the design of evidence-based studies and feasible clinical trials.

RESULTS

In September 2013, a multidisciplinary task force, composed of pediatric practitioners from tertiary care centers experienced in caring for children with OPPN, was convened to address the lack of clinical care guidelines for children with OPPN.

CONCLUSIONS

This consensus statement provides recommendations for ophthalmologic monitoring, outlines treatment indications and forthcoming biologic therapy, and discusses challenges to performing clinical trials in this complicated condition.

Indirect internal carotid-cavernous fistula in infancy

A 4-month-old male infant with proptosis and episcleral injection initially thought to have orbital inflammation was found to have an indirect carotid-cavernous sinus fistula. He was treated conservatively without worsening of symptoms. The authors report the first case of indirect carotid-cavernous sinus fistula in an infant originating from the internal carotid artery.

Optic pathway gliomas: neoplasms, not hamartomas

IMPORTANCE

Optic pathway gliomas are an important neuro-ophthalmic cause of vision loss in children. Their management depends on whether they are considered neoplasms or hamartomas.

OBJECTIVE

To outline the evidence that optic pathway gliomas are slowly growing neoplasms and not hamartomas.

DESIGN

Review of relevant studies in the literature.

SETTING

The authors are from a pediatric tertiary referral center.

RESULTS

The growth patterns and histopathology of optic pathway gliomas are more consistent with those of neoplasms. Spontaneous regression, thought to be a characteristic of hamartomas, can be seen in neoplasms of other types as well as in optic pathway gliomas. Chemotherapy used in low-grade gliomas has been shown to halt or improve vision loss in optic pathway gliomas in many cases.

CONCLUSIONS AND RELEVANCE

Optic pathway gliomas are not hamartomas but truly are neoplasms. Thus, patients should be followed up closely, and chemotherapies should be used when clinical progression occurs. Other more directed therapies will certainly be used in the future.

Ablepharon-Macrostomia syndrome--extension of the phenotype

Ablepharon-Macrostomia syndrome (AMS) is a rare collection of findings characterized by absent or hypoplastic eyelids, fusion defects of the mouth with unfused lateral commissures, abnormal ears, ambiguous genitalia, skin differences including dry and coarse skin or redundant folds of skin, and developmental delay. Fewer than 20 patients have been reported to date. These include a parent and two children and a recent report of a father and daughter, therefore suggesting autosomal dominant inheritance. Here we present one additional sporadic case with an expanded phenotype. This patient has more significant hand and foot anomalies than previously reported.

Pediatric thyroid-associated orbitopathy: the Children's Hospital of Philadelphia experience and literature review

BACKGROUND

As Graves' disease is uncommon in children, Graves' eye disease should be even more unusual. Here we report our experience with Graves' eye disease at the Children's Hospital of Philadelphia and review the literature on ophthalmic findings in children with Graves' disease.

SUMMARY

A retrospective review identified 152 children with Graves' disease seen in the endocrinology clinic of the Children's Hospital of Philadelphia over a 3-year period. Of this cohort, only 26 (17%) were referred to ophthalmology because of prominent ophthalmic manifestations. The ages of the patients ranged from 4 months to 17 years. Sixteen of 26 patients were female. Most patients had mild findings consistent with Graves' disease. Proptosis was noted in 10 of 26 (38%). Lid retraction was present in 6 of 26 (23%). Mild corneal punctuate staining was identified in only 3 of the 26 patients (12%). No patients had strabismus or optic neuropathy. Three newly diagnosed Graves' patients who were seen as the retrospective review was being completed were all girls. All three had normal vision, motility, and fundus exams. Two had mild proptosis, lid retraction, and lid lag on down gaze. None had corneal, motility, or optic nerve pathology. These findings are consistent with previous studies in the literature.

CONCLUSIONS

Eye findings in pediatric Graves' disease are usually mild and typically respond to local measures and control of disturbed thyroid function. Surgery is indicated in a small number of patients for cornea exposure or appearance issues. Graves' disease-associated optic neuropathy has never been reported in the pediatric population.

The histopathologic effects of balloon dacryoplasty on the rabbit nasolacrimal duct

PURPOSE

To examine the histopathologic effects of balloon dacryoplasty on the nasolacrimal duct of the rabbit.

METHODS

Sixteen nasolacrimal ducts of 8 infant white New Zealand rabbits were divided into 3 treatment groups: a control group, a 2 mm balloon dilation group, and a 3 mm balloon dilation group. The LacriCath balloon catheter (Quest, Medical, Allen, TX) was used for nasolacrimal duct dilation according to the manufacturer's recommended human protocol. The rabbits were euthanized at 1, 3, and 7 days after treatment and the nasolacrimal ducts were harvested for histological examination.

RESULTS

There were no significant differences between treatment groups in the number of neutrophils in the lumen, epithelium, and stroma of the duct; the number of monocytes in the stroma of the duct; or in the number of red blood cells in the stroma of the duct. No differences were found in overall cellularity of any type in the nasolacrimal ducts of treated and untreated rabbits. Finally, no histopathologic signs of crush injury were evident.

CONCLUSION

Balloon dacryoplasty does not induce significant inflammation or crush injury in the nasolacrimal duct of a rabbit model.

The male eyebrow: a topographic anatomic analysis

PURPOSE

To study and quantify the topographic anatomy of the male eyebrow and its 3-dimensional relation, based on age and location, relative to the eye and the supraorbital rim.

METHODS

A prospective cohort of male patients seen for routine ophthalmic evaluation age 10 years and older had several eyebrow measurements incorporated in the examination. The presence or absence of brow ptosis was noted on the basis of observation. The location of the eyebrow relative to the center of the pupil, the lateral canthus, and the depth of the supraorbital rim was measured. The data were subjected to statistical analysis.

RESULTS

The study included 444 eyebrows of 222 patients ranging in age from 10 to 86 years, with a mean age of 46.75 years. The incidence of brow ptosis was 7.4%. The mean distance between the lateral canthus and inferior brow (LIBD) was 11.23 mm. The mean distance between the pupil and the inferior brow and the superior brow border was 11.15 mm (PIBD) and 19.8 mm (PSBD), respectively. Statistical analysis demonstrated that the mean brow position did not vary with age. However, there was a significant negative correlation between the position of the eyebrow and the depth of the superior sulcus below the supraorbital rim (correlation coefficient, 0.431 for PIBD and depth and 0.381 for LIBD and depth, respectively). Deeper-set eyes had lower brow position.

CONCLUSIONS

The male eyebrow sits along the supraorbital ridge and has a flat contour. In men without frank brow ptosis, the eyebrow position relative to the pupil and the lateral canthus does not significantly fall with age despite the periocular changes associated with aging. However, 3-dimensional analysis demonstrates that individuals with deep-set eyes have a lower positioned eyebrow then those with a more shallow depth below the supraorbital rim. These findings are helpful in surgical management of the eyelid-eyebrow continuum. The age-related changes in the eyebrow area should be thought of as a 3-dimensional construct with collapse of the structure and not simply descent of the eyebrow.

Comparison of Monocanalicular Stenting and Balloon Dacryoplasty in Secondary Treatment of Congenital Nasolacrimal Duct Obstruction After Failed Primary Probing

PURPOSE

To determine the success of monocanalicular stenting and balloon dacryoplasty as secondary treatment options for congenital nasolacrimal duct obstruction after failed probing surgery.

METHODS

An interventional case series of consecutive secondary balloon dacryoplasty and monocanalicular stenting for congenital nasolacrimal duct obstruction was reviewed. These secondary treatments were used in cases in which a bicanalicular stent would have been used in the past. Seventy-seven nasolacrimal systems in children with epiphora after probing and irrigation surgery were treated with a monocanalicular stent or balloon dacryoplasty. The patients were then evaluated at least 3 months after surgery or after stent removal by using a dye disappearance test. Cases in which there was no significant dye at 5 minutes were considered a success. Cases with residual dye or history of persistent tearing were considered failures.

RESULTS

The monocanalicular stent was used in 35 nasolacrimal systems, whereas balloon dacryoplasty was used in 42 nasolacrimal ducts. The mean age of treatment was 25.2 months for the monocanalicular stent group and 25.8 months for the balloon group. Overall, 32 of 35 (91%) nasolacrimal ducts responded to monocanalicular stenting, whereas 36 of 42 (86%) responded to balloon treatment. When the patient group was further stratified by age, the monocanalicular stenting was 94% successful in children younger than age 2 years and 89% successful for children older than 2 years. The balloon treatment had a success rate of 91% in the younger group and 79% in the older group. Chi-square statistical analysis showed no significant difference between the two treatments or on the basis of age stratification within each treatment group.

CONCLUSIONS

Monocanalicular stenting and balloon dacryoplasty are excellent secondary therapies for congenital nasolacrimal duct obstruction after initial probing and irrigation surgery has failed. These two treatment options are now our procedures of choice for secondary surgery.

Encephalocraniocutaneous lipomatosis: a neurocutaneous syndrome

The neurocutaneous pattern syndromes are a group of disorders characterized by congenital abnormalities involving both the skin and the nervous system for which no identifiable cause has been isolated.(1) Ophthalmologic manifestations of these syndromes are common. These rare syndromes often have overlapping ophthalmic and systemic findings. Examples include encephalocraniocutaneous lipomatosis (ECCL), oculocerebrocutaneous syndrome (OCC), and linear nevus sebaceous syndrome (LNS). Clarifying the diagnostic criteria for these syndromes is a worthy goal because it will help elucidate the phenotypic spectrum of these poorly understood diseases as well as possibly facilitate genetic counseling. In this short report, a case of ECCL is used to illustrate the clinical manifestations of neurocutaneous syndromes.

Orbital presentation of posttransplantation lymphoproliferative disorder: a small case series

OBJECTIVE

To describe a small series of patients with orbital presentation of posttransplantation lymphoproliferative disorder (PTLD).

DESIGN

Retrospective, interventional case series.

PARTICIPANTS

Three patients with orbital presentation of histologically diagnosed PTLD.

METHODS

Review of medical records.

MAIN OUTCOME MEASURES

Measured parameters included vision, proptosis, and tumor extent.

RESULTS

Three cases of orbital PTLD are described. In two of the cases, the tumor initially demonstrated orbital signs and symptoms, whereas in the third case, orbital and systemic signs were synchronous. Two of three patients had disseminated disease discovered at the time of presentation. One adult patient had synchronous presentation of PTLD in the orbit and prostate. One pediatric patient had tumor dissemination to the liver at the time of presentation. The PTLD tumors were classified histologically as diffuse large cell lymphoma of monomorphic or immunoblastic type in all three cases. Treatment included local irradiation, decreased immunosuppression, and antilymphocyte monoclonal antibodies.

CONCLUSIONS

Orbital presentation is a rare manifestation of PTLD. However, ophthalmologists must consider this diagnosis carefully in organ transplant recipients with subtle orbital signs and symptoms at presentation. Early detection may alter prognosis. In each case presented, the diagnosis was established via lesion biopsy and subsequent histologic or flow cytometric evaluation, or both.

Orbital neural-glial hamartoma associated with a congenital tonic pupil

Tonic pupils in children are rare, and only a handful of reports exist in the literature. We present the case of an orbital neural-glial hamartoma in an infant with a congenital tonic pupil and no proptosis. We have previously described this association in another child. This new case, the 6-year follow-up from the previous case, and a discussion of tonic pupils are presented.

Phenotype of the fibroblast growth factor receptor 2 Ser351Cys mutation: Pfeiffer syndrome type III

We present a patient with pansynostosis, hydrocephalus, seizures, extreme proptosis with luxation of the eyes out of the lids, apnea and airway obstruction, intestinal non-rotation, and severe developmental delay. His skeletal abnormalities include bilateral elbow ankylosis, radial head dislocation, and unilateral broad and deviated first toe. The phenotype of this patient is consistent with that previously reported in Pfeiffer syndrome type III, but is unusual for the lack of broad thumbs. Our patient most closely resembles the case described by Kerr et al. [1996: Am J Med Genet 66:138-143] as Pfeiffer syndrome type III with normal thumbs. Mutations in the genes for fibroblast growth factor receptors (FGFR) 1 and 2 have previously been seen in patients with Pfeiffer syndrome type I. The mutation identified in our patient, Ser351Cys in FGFR2, represents the first reported cause of Pfeiffer syndrome type III. An identical mutation was described once previously by Pulleyn et al., in a patient whose brief clinical description included cloverleaf skull, significant developmental delay, and normal hands and feet [Eur. J. Hum. Genet. 4: 283-291, 1996]. In our patient, previously performed single-strand conformation polymorphism analysis failed to detect a band shift; the mutation was identified only after independent sequence analysis.

Unilateral dermis-fat graft implantation in the pediatric orbit

The purpose of this study was to evaluate the role of the dermis-fat graft (DFG) as an orbital implant in the pediatric age group. A retrospective study was made of a series of 16 patients who had undergone unilateral orbital implantation of a DFG. The ages of the patients at the time of surgery ranged from 2 months to 17 years, with followup ranging from 2 to 15 years. Growth of the graft was clinically apparent in the younger children. Increasing proptosis required surgical debulking of the graft in six of eight children who were 4 years old or younger at the time of DFG implantation. None of the eight children who were 9 years or older at the time of DFG implantation required surgical debulking. Indeed, five of the older patients demonstrated some degree of graft atrophy. Dermis-fat grafts placed in the orbits of young children appear to grow after implantation. This growth of the implant may help stimulate orbital growth, potentially leading to more symmetry between the involved and uninvolved sides.

Oral mucous membrane grafts for corneal protection to permit prosthetic shell wear

Conjunctival flaps are commonly used to cover the cornea in patients who otherwise can not tolerate a scleral shell. An alternative method of protecting the cornea, oral mucous membrane grafting, is described herein. Ten patients had oral mucous membrane grafting to the cornea. Patients ranged from 5 months to 47 years of age. Diagnoses included partial cryptophthalmia, microphthalmia, congenital orbital fibrosis syndrome, juvenile active ossifying fibroma, and trauma. All patients had poor visual function in the affected eye. Patients were either intolerant of scleral shell wear or had other contraindications to the use of a shell over an unprotected cornea. Following mucous membrane grafting (follow-up, 1-3 years), all patients were successfully fitted with prostheses and obtained good cosmetic results.

Prominent proptosis in childhood thyroid eye disease

BACKGROUND

Orbital signs and symptoms occur in approximately one half of children with Graves disease, but the symptoms are usually minor and limited to the eyelids. Prominent proptosis is uncommon in children with this disorder.

METHODS

Review of eight children with prominent proptosis associated with thyroid eye disease. Four patients were treated at the Children's Hospital of Philadelphia, the other four at the Columbia Presbyterian Medical Center.

RESULTS

At initial presentation, children ranged in age from 3 to 16 years. There were five girls and three boys. Seven of eight children had hyperthyroidism at ophthalmic presentation. Four patients had restrictive myopathy, and all of the seven patients who underwent neuroimaging had extraocular muscle enlargement. Five patients were treated with lubrication. Two underwent orbital fat decompression. One patient had thyroid eye disease and myasthenia gravis.

CONCLUSIONS

Proptosis in childhood thyroid eye disease usually is associated with a hyperthyroid state. The proptosis may be dramatic, but corneal exposure and restrictive myopathy are seen in only some of the patients. Neuroimaging shows enlarged extraocular muscles. Most children with this complication can be treated conservatively with topical lubrication, but orbital fat decompression may be considered in patients with more advanced conditions.

Results of dacryoscintigraphy in massage of the congenitally blocked nasolacrimal duct

Between November 1990 and November 1993, 580 children with lacrimal outflow obstruction were examined at the Children's Hospital of Philadelphia. After excluding patients previously treated for nasolacrimal duct obstruction, we obtained a prospectively selected series of 20 children for this study. These patients underwent dacryoscintigraphy before and immediately after lacrimal sac massage to investigate the effect of external compression on fluid movement within the lacrimal outflow system. In 12 patients, tracer did not enter the lacrimal outflow system on the side(s) of obstruction. The absence of radiopharmaceutical correlated with clinical obstruction. In eight patients, tracer was noted to enter the lacrimal sac. After massage of the lacrimal sac, we observed progression of the tracer in five of the eight subjects. In these eight subjects, the pre- and postmassage tear column measurements showed a relative increase of 34.3%. Massage of eight clinically normal ducts showed a relative increase of 2.4% (p = 0.06). We conclude that progression of the tear column after lacrimal massage can be demonstrated on dacryoscintigraphy.

Tonic pupil and orbital glial-neural hamartoma in infancy

PURPOSE/METHODS

Tonic pupils in early childhood are rare. We studied an otherwise healthy 31/2-month-old girl who had a right pupil that was poorly reactive to light, without other signs of oculomotor nerve palsy.

RESULTS/CONCLUSIONS

Constriction of the right pupil after instillation of 0.125% pilocarpine eyedrops confirmed denervation hypersensitivity, consistent with a tonic pupil. There was no strabismus or proptosis. A magnetic resonance imaging scan demonstrated a right orbital mass, interposed between the lateral and inferior recti muscles. Biopsy was consistent with a benign, glial-neural hamartoma. Thus, in this young patient, a tonic pupil was associated with a benign orbital mass.

Congenital and acquired anophthalmia

Anophthalmia is an absence of ocular tissue in the orbit. Important aspects in the diagnosis, evaluation, and treatment of both congenital and acquired anophthalmic patients are reviewed. Congenital and acquired anophthalmia differ in etiology, but many concepts of management can apply to either category. Specific steps in the evaluation and treatment including the proper timing for medical and surgical intervention will be discussed. The major goals for the ophthalmologist are to optimize motility and symmetry of the eyelids and orbit and coordinate efforts with other medical specialties.

Ophthalmic features and visual prognosis in the Treacher-Collins syndrome

The ocular findings and visual prognosis were reviewed in 24 patients with the Treacher-Collins syndrome who were evaluated in the craniofacial clinic in the Division of Pediatric Ophthalmology at Children's Hospital of Philadelphia between 1980 and 1991. All patients had some abnormality. Vision loss was present in 37% of patients. Amblyopia was present in 33%, significant refractive errors were present in 58%, and anisometropia was documented in 17%. Strabismus was present in 37% and significant lid and adnexal abnormalities were seen in 96%. The prognosis for normal vision in at least one eye is good but vision loss secondary to amblyopia is more resistant to treatment owing to other medical problems and social concerns.

Evaluation of a collagen/hydroxylapatite implant for orbital reconstructive surgery

A variety of autogenous and alloplastic materials have been used to correct enophthalmos. Hydroxylapatite (HA), is a calcium-phosphate-based compound that has been extensively studied as a bone replacement material. We studied the properties of a new dense particulate form of HA in a collagen matrix (PFC/HA) implanted in the subperiosteal space of ten rabbit orbits for a period of 6 months. All animals were studied with pre- and postoperative computed tomography (CT) scans, and measurements of induced proptosis and implant volume were made. The proptosis induced by the implant averaged 2.2 mm and was stable over a 6-month period. Implant volume was constant throughout the study. Three-dimensional computer-generated images of the soft tissue, skeletal, and implant surfaces confirmed the implant stability. All animals were studied histologically with fluorochrome bone markers, which revealed minimal foreign body reaction to the implant, no evidence of infection, and marked fibrovascular ingrowth. We found the PFC/HA to possess properties that make it an ideal implant material: ease of availability, ease of handling, no resorption, minimal immunogenicity, infection resistance, no observed migration, biointegration, and no risk of disease transmission. PFC/HA may make an excellent implant material to manage orbital volume.

Congenital unilateral fibrosis, blepharoptosis, and enophthalmos syndrome

The authors report four cases of the rarest form of the congenital fibrosis syndrome. This disorder is exhibited in infancy as unilateral blepharoptosis, strabismus, limited ductions, globe displacement (enophthalmos and blepharoptosis), and decreased vision, usually due to amblyopia. Forced ductions are positive and surgical exploration confirms anomalous muscle structure. Computed tomography and magnetic resonance imaging studies in these four patients were diagnostically beneficial, showing extraocular muscle and tendinous insertion involvement, and poorly defined intraconal and extraconal masses that had the appearance of scar or inflammatory tissue. All patients had globe displacement. The opposite eye and intracranial contents were normal in all of our patients. Results of histopathologic examination obtained at surgery in three of these patients show replacement of affected structures by fibrous tissue and included the extraocular muscles, orbital fat, Tenon's capsule, and conjunctiva.

Ocular and adnexal findings in patients with facial microsomias

The authors reviewed the ocular findings in 49 patients with facial microsomias not considered part of a known syndrome. Five patients had bifacial microsomia, and 44 patients had hemifacial microsomia. These patients were evaluated in the Craniofacial Clinic in the Division of Pediatric Ophthalmology at Children's Hospital of Philadelphia between the years 1979 and 1989. Ocular or adnexal abnormalities were present in 67% of patients. Visual loss was present in 8% of eyes. Amblyopia was present in 16% of patients. Significant refractive errors were present in 27% of patients, and anisometropia was documented in 8%. Strabismus was present in 22% of patients, and significant lid and adnexal abnormalities were seen in 41%. Because ocular or adnexal findings present in a significant percentage of patients with more mild forms of facial microsomias, regular examinations to uncover and treat these abnormalities are recommended.

Visual loss in patients with craniofacial synostosis

We reviewed the ocular findings in patients with cranial stenosis, who were seen in the Craniofacial Clinic at The Children's Hospital of Philadelphia, to determine the prevalence, pattern, and etiology of visual loss. There were 15 patients with Apert syndrome, 25 patients with Crouzon syndrome, and 18 patients with other forms of craniofacial synostoses. Visual loss occurred in 17 eyes of 11 patients with Apert syndrome, 14 eyes of 11 patients with Crouzon syndrome, and 12 eyes of 8 patients with other craniofacial synostosis syndromes. Refractive errors and strabismus were present in the majority of these patients. Amblyopia due to strabismus, ametropia, or ptosis was the major reason for visual loss in all three groups of patients. Structural abnormalities contributed to loss of vision in six eyes.

Congenital craniofacial anomalies of ophthalmic importance

Congenital craniofacial abnormalities frequently require ophthalmic evaluation and surgical management. Called upon to perform as part of the craniofacial team managing the often severely deformed craniofacial patient, the ophthalmologist must bring a basic knowledge of craniofacial syndromes and developmental anatomy, as well as clinical acumen to help preserve or improve ocular and adnexal function. As an introduction to this area of ophthalmology, the clinical features, classification, appropriate facial embryology, assessment and surgical considerations of the various congenital craniofacial abnormalities are reviewed. The expanding availability of craniofacial surgeons and surgical teams along with improved surgical results will ultimately require an increasing involvement by many more ophthalmologists in the evaluation and management of these congenital abnormalities.

The ophthalmic manifestations and treatment of the amniotic band syndrome

The amniotic band syndrome is an unusual cause of craniofacial deformities. The syndrome, which is initiated by rupture of the amnion, results in an unpredictable combination of compression deformities of the fetus, construction or amputation defects of the extremities, and craniofacial clefting deformities. The type and extent of ophthalmic abnormalities are dependent on the band location and timing. They include a combination of bony orbital clefts or hypertelorism; lid anomalies such as colobomas, ptosis, and ectropion; lacrimal outflow obstruction; and globe involvement. We review the clinical course of 14 patients diagnosed with, or suspected as having, this syndrome and describe the methods of treatment. In most instances, multiple surgical procedures were required to restore function. Satisfactory cosmesis proved more difficult to obtain.

Timing of Silastic tubing removal after intubation for congenital nasolacrimal duct obstruction

One thousand five hundred twenty-one patients (2,038 eyes) with congenital nasolacrimal duct obstruction were reviewed at The Children's Hospital of Philadelphia. Of these, 174 patients with congenital dacryostenosis involving 192 eyes underwent polymeric silicone (Silastic) intubation to treat the dacryostenosis. All patients had undergone at least several months of conservative management consisting of topical antibiotics and massage. All had undergone at least one probing and irrigation. Congenital dacryostenosis as well as resolution of symptoms were confirmed by clinical examination and use of a modified dye disappearance test. In 192 eyes the overall success rate was 83.33%. When broken down into age group, progression of success rates were from 100% in the 6-13 month age group to 79.6% in the over 24-month age group. Success rates differed significantly according to how long the Silastic tubing remained in position, especially in older age groups. The data suggest that Silastic intubation is a successful means of treating congenital dacryostenosis and that one should consider leaving the silastic in place for 6 months when possible.

Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction

A series of 427 patients with congenital dacryostenosis involving 572 eyes was seen at the Children's Hospital of Philadelphia. All patients were treated conservatively with antibiotics and massage prior to decision by the parents to request probing. Congenital dacryostenosis, as well as resolution of symptoms, were confirmed by clinical examination and use of a modified dye disappearance test. In 572 eyes, the success rate of initial probing was found to be 97% under 13 months of age. Over 13 months, however, the mean success rate was found to be 54.7%. When broken down into smaller age categories, a stepwise progression was observed from 76.4% between 13 and 18 months to 33.3% for patients probed after 24 months. In addition, the number and complexity of subsequent procedures appeared to increase along with the age at which the initial probing was performed. These data suggest that initial probing should be done prior to 13 months of age depending on the severity of symptoms and parent compliance with medical management.