Oculoplastic Surgery

No parent wants her child to have to undergo surgery. It might help you to know that the caregivers in Boston Children’s Hospital's Pediatric Oculoplastic Program have a long and distinguished history of surgically repairing problems that affect children’s eyelids, lacrimal (tear) system and orbit.

Our doctors can help, first by identifying the severity of the problem—some don’t even require treatment—and then by working with you and your family to design an individualized plan of care.

Here’s some information about oculoplastic surgery and what makes Children’s different.

What are some of the more common conditions requiring oculoplastic surgery?

• Congenital ptosis — Drooping upper eyelids (ptosis) are caused by a problem with your child’s eyelid muscles, usually the levator muscle.
  • Surgery is often necessary if the condition interferes with your child’s vision.

• Tear duct obstruction —About 5 percent of all infants have an immature tear drainage apparatus.
  • While this condition usually improves spontaneously during the first year of life, we sometimes have to perform a surgical procedure to open up the tear duct.

• Orbital dermoids — Some children experience this overgrowth of normal, non-cancerous tissue in the orbital region of the eye.
  • If the dermoid grows large, it can be at risk of rupturing, which can make removal more difficult and cause significant inflammation. If it is allowed to continued growing it could affect the ability of the eyeball to move well.

• Infantile hemangioma — This benign vascular tumor can grow rapidly and put pressure on the eye or cause the eyelid to droop over the pupil.
  • If the hemangioma expands and threatens the eye, it may need to be removed or treated with medication.

• Trauma — Children can sometimes injure their lacrimal system or orbit during an accident or while playing sports.

Questions to ask your doctor

You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s treatment team and that you understand your provider’s recommendations.

If your child is scheduled for oculoplastic surgery and you’ve set up an appointment, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling like you have the information you need.

Here are some questions you might want to ask:

• How did you reach the decision that my child should have surgery at this time?
• When should we have the surgery performed?
• Is there anything we need to do to prepare for surgery?
• Is it safe to use general anesthesia?
• What will the recovery period be like?
• How should I care for my child after surgery?

We’ve also put together some general information about how to prepare for surgery and what to expect. To read more, click here.

FAQ

Q: What is oculoplastic surgery?

A: Oculoplastics, or oculoplastic surgery, is literally plastic surgery of the eyelids. It’s a specialty of ophthalmology that focuses on three areas — the orbit, the eyelids, and the lacrimal (tear) system.

Q: What is the surgical process like?

A: We’ve put together some general information about how to prepare for surgery and what to expect.

Q: What is the long-term outlook for my child?

A: Every child is unique, and your child’s long-term vision depends upon your child’s exact condition. But generally speaking, most of these surgical procedures have high success rates.

Ptosis — Children who have surgery to correct congenital ptosis sometimes need to have another procedure when they are older.

• This may be due to the fact that the surgery relies upon the formation of scar tissue to hold the stitch in place. Sometimes this loosens with time. Other times the lid crease or symmetry between the two eyes can be improved.

Your doctor will discuss this possibility with you in more detail.

Tear duct obstruction — For 80 percent of the children who have the surgery, one probe into tear duct is sufficient to remove the obstruction. For the other 20 percent, more complicated surgery may be necessary.

Orbital dermoids — Once they are removed, they don’t grow back.

Infantile hemangioma — Once the hemangioma is removed or stops growing (usually when your baby is around one year old) it rarely recurs.

Q: Are there any other resources about oculoplastic surgery out there?

A:The American Society of Ophthalmic and Plastic and Reconstructive Surgery has an informative page.

We’ve got an appointment with the Pediatric Oculoplastic Program. What should we expect at our first visit?

Boston Children’s Hospital’s Pediatric Oculoplastic Program team is committed to ensuring that your experience is as pleasant as possible.

• Our facilities are child-friendly and our staff is highly experienced in communicating with children and making them feel safe and comfortable.

We know that the family is the most important source of emotional support for children. That’s why we provide families with information about our services, tests and treatments in advance so that you know what to expect and in turn, can help prepare your child for a visit to the doctor.

What you discuss with your doctor at your child’s appointment will depend upon your child’s condition, but all visits begin the same way.

Upon arrival, you’ll meet with an orthoptist (eye technician) who will take your child’s basic medical history, give him a vision test and evaluate his depth perception and basic eye function.

Your child may also have a complete eye exam with dilation.

• For older children we use eye drops, and we have a special misting spray that’s easier for younger children.
• It’s necessary to wait about 20 minutes for your child’s eyes to become dilated; during this time, you may relax in our waiting room which offers games, books and toys.

You’ll then see the doctor who will complete your child’s eye exam by looking at the inside of his eyes and examining the following areas:

• optic nerve
• retina
• focal point of the eye

After the eye exam is complete, you’ll speak with the doctor about your child’s diagnosis and treatment plan, which will depend upon his condition.

Common conditions and treatment plans

Every child is unique, and your child’s long-term vision depends upon your child’s exact condition. But generally speaking, most of the conditions we treat can be corrected with relatively simple surgical procedures.

Read on to learn about some common treatment plans. For more information about recovery from these surgical procedures, see the Long-Term Outlook section of this page.

Congenital ptosis — If your child has a very severe case of ptosis with almost no eyelid function, she could be at risk of losing vision, so the doctor may choose to operate when your child is as young as 5 to 6 months old.

However, this is very rare; a more common time for surgery is around a year old because by that time it will be clearer how well the eyelid muscle (levator) is actually going to work. Once your doctor is able to assess your child’s levator function, she’ll know which surgical procedure is most appropriate.

• Levator resection — Uses an incision to tighten the natural levator muscle, which elevates the upper eyelid.
  • This option is appropriate for children whose levator muscle has some function.

• Levator sling – This is a more complex operation in which the muscles of the forehead may be used to assist in the elevation of the eyelid.
  • This option is used for children whose levator muscle has almost no function.

If your child has a relatively mild case of ptosis and his vision is not affected, you may elect to wait until your child is older and can decide for herself whether she wants to have the surgery.

Tear duct obstruction — Your doctor will often perform an assessment by putting a small amount of pressure on the lacrimal system and observing the results. She’ll also check to make sure the external apertures of the system are open to allow tears to come out.

Typically, your doctor will want to wait to perform surgery until your child is at least a year old. The reasons for this are twofold:

• This condition gets better on its own in about 70 percent of kids by the time they’re a year old.
• We prefer not to administer a general anesthetic to children younger than 1 unless it’s medically necessary.

Orbital dermoids — If your child’s dermoid is located near the nose or has any other abnormal characteristics, your doctor may order an MRI to ensure that she doesn’t have any other associated conditions.

Then you’ll discuss what the surgical process will be like and a timeline for treatment.

• Typically, your doctor will recommend performing the surgery before your baby is a year old because the risk of rupture is greater once your child begins to walk.

Infantile hemangioma — These benign vascular tumors can be a problem if they expand enough to cause the eyelid to droop and cover the pupil or if they’re deep and press on the orbit of the eye, which can cause a distortion in vision or amblyopia (lazy eye).

• If your child’s hemangioma is growing rapidly, your doctor may elect to remove it surgically or treat it with oral or injectable steroids.

• Propranolol is another medication that is sometimes used to treat hemangiomas; however, the effectiveness and risk of this drug on children with these conditions is still being studied.

What is the long-term outlook for my child?

Every child is unique, and your child’s long-term vision depends upon your child’s exact condition. But generally speaking, most of these surgical procedures have very high success rates.

Ptosis — Children who have surgery to correct congenital ptosis sometimes need to have another procedure when they are older.

• This may be due to the fact that the surgery relies upon the formation of scar tissue to hold the stitch in place. Sometimes this loosens with time. Other times the lid crease or symmetry between the two eyes can be improved.

Your doctor will discuss this possibility with you in more detail.

Tear duct obstruction — For 80 percent of the children who have the surgery, one probe into tear duct is sufficient to remove the obstruction. For the other 20 percent, more complicated surgery may be necessary.

Orbital dermoids — Once they are removed, they don’t grow back.

Infantile hemangioma — Once the hemangioma is removed or stops growing (usually when your baby is around one year old) it rarely recurs.

We understand that you may have a lot of questions when your child is scheduled for oculoplastic surgery. We’ve provided some answers to those questions in these pages, but there are also a number of other resources at Boston Children’s Hospital to help you and your family through this difficult time.

• The Hale Family Center for Families is dedicated to helping families locate the information and resources they need to better understand their child’s particular condition and take part in their care. All patients, families and health professionals are welcome to use the Center’s services at no extra cost. The center is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.

• The Boston Children’s Department of Spiritual Care (chaplaincy) is a source of spiritual support for parents and family members. Our program includes nearly a dozen clergy members—representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian, and United Church of Christ traditions — who will listen to you, pray with you, and help you observe your own faith practices during your child’s treatment.

Children’s Behavioral Medicine Clinic helps children who are being treated on an outpatient basis at the hospital — as well as their families — understand and cope with their feelings about:

• being sick
• facing uncomfortable procedures
• handling pain
• taking medication
• preparing for surgery
• changes in friendships and family relationships
• managing school while dealing with an illness
• grief and loss

Visit here or call 617-355-6688 to learn more.

• Children’s Pediatric Psychiatry Consultation Service is made up of expert and compassionate pediatric psychologists, psychiatrists, social workers and other mental health professionals who understand the unique circumstances of hospitalized children and their families. The service works with children who have been admitted to the hospital—and their family members—and operates on a referral basis. For more information about the service, visit here [LINK: Pediatric Psychiatry Consultation Service homepage]. If you are interested in setting up an appointment, please speak to your child’s doctor.

• The Experience Journal was designed by Children’s psychiatrist-in-chief David DeMaso, MD and members of his team. This online collection features thoughts, reflections, and advice from kids and caregivers about their medical experiences.

Visit our patient resources pages for all you need to know about:

• getting to Children’s
• accommodations
• navigating the hospital experience
• resources that are available for your family

Online resources: The American Society of Ophthalmic and Plastic and Reconstructive Surgery has an informative page.

At Boston Children’s Hospital, we’re continually learning from our experiences with patients, evaluating the most current data and studying the causes of diseases and new treatments with the aim of developing innovative methods for caring for kids.