EOM Issues. Treatment Options. Surgical Intervention. Surgical Intervention. Surgical Techniques

Transcription

1 Common Pediatric Disease and Anomalies: Management & Co-Management EOM Issues Identification R. Michelle Welch, O.D. NSU Oklahoma College of Optometry Treatment Options Refractive Devices Therapy Surgical Intervention Surgical Intervention Pre-Operative Management Surgical Techniques Weakening Procedures Strengthening Procedures Recession Disinsertion Posterior Fixation Suture Surgical Intervention Post-operative Management Watch for infection Check sutures Monitor BV status long term Resection Tucking Advancement Adjustable Suture 1

2 Meesmann Dystrophy Corneal Dystrophies/Degenerations Meesmann Reis-Buckler Thiel-Behnke Lattice Dystrophy Type I Granular Dystrophy Type I Macular Dystrophy PPMD CHED Cystinosis Reis-Buckler Dystrophy Autsomal Dominant stromal dystrophy Onset 1st to second decade Painful recurrent erosions Grey-white fine round polygonal opacities, most dense centrally VA may be affected due to scarring K sensation reduced Treatment: PRK or lamellar PKP can recur in graft Lattice Dystrophy Type I Autosomal Dominant Stromal dystrophy Onset end of 1st decade with recurrent erosions which precede stromal changes Anterior stromal, glassy, refractile dots Dots coalesce into fine lattice lines Deep and outward spread spares periphery Generalized stromal haze progressively affects vision Treatment PKP or Lamellar KP Thiel-Behnke Dystrophy Very rare epithelial dystrophy Autosomal dominant Onset 1st 2 years of life with ocular irritation Tiny intraepithelial cysts mostly central, don t reach limbus Treatment other than lubrication not normally required Autosomal Dominant Bowman layer dystrophy Onset end of the first decade with recurrent erosions Similar to ReisBuckler except opacities more in a honeycomb pattern May not be necessary less problems than ReisBuckler Granular Dystrophy Type I Autosomal Dominant Stromal dystrophy Onset in 1st decade vision not usually affected at that time Mild photophobia, RCE s uncommon 2

3 Granular Dystrophy Type I Macular Dystrophy Signs in order of appearance: Small, white, demarcated deposits in central anterior stroma Overall pattern is radial or disc shaped Initially corneal stroma between the opacities is clear Gradual increase in number and size of deposits Spreads deeper and outward does not reach limbus Gradual confluence, hazing of stroma Corneal sensation affected Posterior Polymorphous Dystrophy Rare Autosomal dominant Asymptomatic Onset at birth Subtle vesicular endo patterns No treatment required Least common stromal dystrophy Error of keratan sulphate metabolism Autosomal Recessive Onset towards end of first decade Anterior stromal haze, central cornea Greyish-white, dense, focal, poorly defined spots in anterior stroma Increasing opacification Erosions rare Eventual full thickness stromal involvement Treatment PKP can recur in graft Congenital Hereditary Endothelial Dystrophy Rare, focal or generalized absence of endo 2 forms one AD, one AR Onset is perinatal Bilateral, symmetrical K edema Cornea appearance from blue-grey ground glass appearance to total opacification. Treatment - PKP Cystinosis Rare, AR Widespread tissue deposition of cystine crystals from defect in lysosomal transport Systemic issues growth retardation, renal failure most severe die by 2nd decade Keratopathy present by 1 YO crystals throughout entire stromal peripherally, anterior centrally Treatment with topical cysteamine can reverse K deposition Corneal Treatment - PTK Pre-operative Clear up blepharitis any other active infection prior to surgery Attempt to stabilize tear film Post-operative BCL placed Broad spectrum topical antibiotic Monitor daily until epithelium healed 3

4 Corneal Treatment - PKP Lamellar vs Total Pre-operative Corneal Treatment - PKP Clear any infection in area Post-operative Graft Rejection Topical steroids q2h initially very slow taper may be on for year Mydriatic bid x 2 weeks (or more) DO NOT REMOVE sutures (12 18 mo) RGP fit later to optimize VA Watch palpebral conj for GPC Watch for wound leak early Watch for infection Endothelial rejection is most common and most severe Predisposing factors Inflammation Neo Large grafts (>8mm), eccentric graft Infection Glaucoma HLA Class I matching can help decrease risk of type IV hypersensitivity (antigens present in donor tissue) Corneal Treatment - PKP Graft Rejection Symptoms Blurred vision, photophobia, dull periocular ache BUT many asymptomatic until advanced! Signs Ciliary injection and anterior uveitis Elevated line of abnormal epithelium SEI s Linear pattern of KP s associated with area of inflammation at graft margin Stromal edema indicative of graft failure Coloboma - Eyelid Unilateral or bilateral Partial or fullthickness eyelid defect Eyelid development incomplete Treatment of small defects involves primary closure larger defects require skin grafts and flaps Coloboma - Eyelid Pre-Operative Oral Antiobiotic +/Clear any active infection Post-Operative Sutures Watch for infection Oral antibiotic Follow Up schedule 4

5 Nasolacrimal Duct Obstruction Nasolacrimal Duct Obstruction Valve of Hasner is the last portion of the lacrimal drainage system to become patent Usually opens soon after birth Epiphora affects 20% of neonates Spontaneous resolution in 96% within the first 12 months Rule out congenital glaucoma in infant with watery eye Treatment Options Probing Usually delayed until 12 months old Probing in kids up to 2 yo usually successful Failure usually due to abnormal anatomy Balloon Dacryoplasty Probing DCR Balloon Dacryoplasty Dacryocystorhinostomy DCR indicated if probing fails but usually delayed until pt 3-4 yo Goal to establish communication between lacrimal sac to nasal mucosa in the middle of nasal meatus Balloon DCP Video Similar to probing Uses addition of balloon to help open passage 5

6 Lacrimal Surgery Herpes Simplex Dermatitis For all consider prophylactic antibiotic pre-op drop and/or oral Clear all infection (lids, conj, lacrimal sac) Post op monitor sutures or tubes if any Antibiotic-steroid combo qid up to 3 weeks +/- continue oral antibiotics Re-assess patency of system at 6 weeks Prodromal facial and lid tingling lasting about 24 hours. Eyelid and periorbital vesicles on the lid margin that break down over 48 hours. Associated papillary conjunctivitis, discharge and lid swelling. Dendritic corneal ulcers can develop, especially in atopic patients. Gradual resolution over 6 to 8 days. Involvement can be very severe in atopic patients (eczema herpeticum. Herpes Simplex Dermatitis Topical antiviral (acyclovir) 5 times daily for 5 days. This tends to be messy when rubbed on the skin. Oral acyclovir 400mg 5 times daily for 3 days is usually better tolerated than topical treatment. Add flucloxacillin (500mg q.i.d) or erythromycin (250mg q.i.d) if there is eczema herpeticum (to treat secondary staphylococcal infection) PHTHIRIASIS PALPEBRARUM Mechanical removal of the lice and associated lashes with fine forceps. Topical yellow mercuric oxide 1% or petroleum jelly applied to the lashes and lids twice a day for 10 days. Delousing of the patient, family members, clothing and bedding is important to prevent recurrences Symptoms consist of chronic irritation and itching of the lids. Signs The lice are anchored to the lashes by their claws The ova and their empty shells appear as oval, brownish, opalescent pearls adherent to the base of the cilia Conjunctivitis is uncommon Lids and Adnexa PHTHIRIASIS PALPEBRARUM Laceration All patients considered for tetanus All patients receive complete exam If possibility of orbital foreign body, ultrasound, maybe CT needed Clean wound, irrigate with saline Inspect area for retained foreign body 6

7 Lids and Adnexa Lacerations that should be referred Lids and Adnexa Associated with ruptured globe Involving lacrimal drainage system Involving levator or superior rectus Associated with intraocular foreign body Associated with extensive tissue loss > 1/3 of lid or severe distortion of anatomy Lacerations should consider referring depending on comfort factor Deep laceration involving lid margin will require two layer closure Superficial lacerations can easily be repaired with simple interrupted sutures Antibiotic ointment bid Oral antibiotic recommended Preparing for repair Aligning canaliculus Refer? Refer? 7

8 Ptosis secondary to??? Full Thickness Laceration Repairing Full Thickness Laceration Conjunctival Laceration Conjunctival Laceration Exam to rule out globe penetration If no penetration - in office treatment Antibiotic ointment Cycloplege Patch Some recommend if >1.5 cm, suture 8

9 Contusion BlowBlow-Out Fracture Complete exam to rule out ruptured globe, Blow out fracture, Corneal abrasion Cold compresses x 3 days then can start warm If too swollen initially to inspect, do as much as possible, recall and ensure no further complications Signs and Symptoms Pain, especially on vertical eye movement Double vision Recent history of trauma Eyelid swelling after nose blowing Restriction of eye movement Hypoesthesia of infraorbital nerve BlowBlow-Out Fracture BlowBlow-Out Fracture Testing/indications for referral Complete exam Check sensation of check and upper lip Check for eye movement restriction If restriction lasts > 1 week - forced duction testing CT scan of orbit - referral for repair if large fracture found, if persistent diplopia, or severe enophthlamos BlowBlow-Out Fracture BlowBlow-Out Fracture Treatment Nasal decongestants bid x days Oral antibiotic x days (keflex qid) Instruct patient not to blow nose Ice packs for first hours Orbital roof fracture neurosurgical consult recommended 9

10 Lids and Adnexa - Burns Chemical burn acid, base, solvents, detergents, irritants Chemical Burn Treatment Thermal burn Lids and Adnexa - Burns Cigarettes, hot metal or oil, curling irons Radiation burn Sunbathing/tanning bed, snow or water skiing, fishing Copious irrigation Check ph - when neutral complete exam Check fornices to ensure no material left Cycloplege, antibiotic ung, pressure patch With severe burn, may need referral Lids and Adnexa - Burns Radiation burn treatment Cool compresses Cycloplege Antibiotic/steroid combo sol May need analgesia Do not patch if lids are burned Blanching of conjunctiva Severe cornea edema Lids and Adnexa - Burns Thermal Burn Treatment Debride necrotic tissue Cycloplege Antibiotic/steroid combo solution Do not patch if lids burned 10