Paediatrics: Orbit and eyelids

Orbit and eyelids

Blepharitis and meibomian cyst/chalazion

Blepharitis is a common chronic inflammation of the lid margin, which can result in recurrent styes, meibomian cysts and, occasionally keratitis. The eyelid margins are red and crusty.

Parents should clean their child’s lid margins using a flannel soaked in a hand-hot mild baby shampoo solution at bath time. An antibiotic ointment e.g. chloramphenicol can then be applied to the lid margins with a finger-tip. Styes and cysts often respond to this treatment too. If a meibomian cyst persists for months and becomes hard, incision, and curettage under GA may be required.

Congenital eyelid abnormalities

•   Entropion (in-turned lid) and ectropion (out-turned lid) are uncommon in children.

•   Lower lid epiblepharon can resemble entropion since the lower lashes are in turned due to a fold of skin close to the lid margin. This is seen more commonly in oriental children and resolves as the face grows although repeated corneal abrasion may necessitate surgical correction.

•   Congenital ptosis due to levator dystrophy can cause unilateral or bilateral ptosis. Neurological causes can be excluded clinically. If the lid covers the visual axis, amblyopia will rapidly ensue.

•   Occlusion therapy may be required but, unless the ptosis is severe, surgery is delayed until pre-school age.

Congenital naso-lacrimal duct obstruction

·  A common cause of watery and sticky eye(s) in infancy.

·  Concurrent conjunctivitis is unusual and the eyes are white despite copious discharge.

·  The majority will improve in the first few months of life.

•   Advise parents to massage the lacrimal sac (located just inferiorly to the medial canthus) firmly with a finger when the baby is feeding.

•   This will express the sac contents into the palpebral fissure where the discharge can be cleaned away with sterile water and a cotton wool pad. It is not necessary to swab the eye or start topical antibiotics if the eye is white.

•   Symptoms persisting beyond 12mths warrant referral for consideration of syringe and probing of the tear ducts.

Capillary haemangioma of the lid

•   These may be deep and bluish or a superficial ‘strawberry’ naevus. It can enlarge and cause amblyopia due to ptosis or induced astigmatism in the first years of life.

•   Occlusion therapy and spectacle correction are often necessary.

Oral propranolol is effective at shrinking the lesion and has replaced oral and steroid injections in the management of sight threatening haemangioma.

• Exclusion of a congenital heart defect and intra-cranial haemangioma associated with PHACES syndrome is necessary prior to propranolol therapy.

• Port wine stains involving the eyelids may cause glaucoma on the affected side. Ophthalmic referral is required for screening.

Pre-septal, peri-orbital and orbital cellulitis

Pre-septal cellulitis

·This is a bacterial infection involving the eyelids and tissue anterior to the orbital septum.

• The source may be from skin, e.g. an infected insect bite, trauma or meibomian cyst, dacryocystitis (lacrimal sac abscess) or deeper, such as sinusitis.

• Commonest organisms are Staph. aureus and B haemolytic Streptococcus. Pre-septal cellulitis in a well child can be treated with oral antibiotics.

• Since orbital involvement can develop within in hours, children with severe pre-septal cellulitis secondary to URTI who are systemically unwell should be admitted and started on IV antibiotics (see Orbital cellulitis).

Peri-orbital cellulitis

• Infection of the peri-orbital skin. This is usually due to infection by either S. aureus or H. influenzae type b (if not immunized).

• May occur s to paranasal or dental abscess in older children. Children are often systemically unwell with fever, erythema, and tenderness over the affected area.

• This requires prompt treatment with a 5–7-day course of IV antibiotics.

• Untreated peri-orbital cellulitis may develop into orbital cellulitis with evolving ocular proptosis, limited ocular movement, and decreased visual acuity.

• May rarely be complicated with intracranial abscess formation, meningitis, or cavernous sinus thrombosis.

• A CT scan of brain should be considered to exclude these complications if suspected.

Orbital cellulitis

·Infective orbital cellulitis arises from bacterial infection of the para-nasal sinuses (consider fungal infection in immunosuppressed children).

·Features include peri-orbital oedema, proptosis, and limited eye movements.

• An ophthalmic emergency, failure to treat adequately will result in visual loss and, potentially, cavernous sinus thrombosis.

• High dose IV second generation cephalosporin (and metronidazole if over 8yrs) without delay.

• Nasal decongestants can be helpful. Children should be co-managed with the ophthalmology and ENT teams.

CT scanning may detect orbital abscess formation, which requires surgical drainage.