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Eyelid Coloboma

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Updated: Nov 2, 2007

Introduction

Background

An eyelid coloboma is a full-thickness defect of the eyelid. Although an eyelid coloboma can occur in many locations, the most common position is at the junction of the medial and middle third of the upper lid. No lid appendages or accessory structures are usually seen within the coloboma.

Pathophysiology

An eyelid coloboma may occur either congenitally or as a result of trauma (eg, accidental, surgical). An eyelid coloboma is an almost constant feature of Treacher Collins syndrome, which is autosomal dominant with variable penetrance and expressivity.

Upper eyelid coloboma is often associated with cryptophthalmos and, as a result, can occur in any genetic diseases involving cryptophthalmos, including Fraser syndrome (cryptophthalmos syndrome) and Manitoba Oculotrichoanal (MOTA) syndrome.1,2

A case review of upper eyelid coloboma with or without cryptophthalmos included 26 children (age range, 1 d after birth to 15 y).3 Of these 26 children, 19 had upper eyelid coloboma, 4 had classic cryptophthalmos, and 3 had both eyelid coloboma and cryptophthalmos. Of the 19 cases of upper eyelid coloboma, 5 occurred in isolation, 11 were associated with facial deformities, and 3 were part of a first arch syndrome (according to the Mustarde classification). All cases of classic cryptophthalmos were sporadic and nonsyndromic.

In this case review, Nouby concluded that upper eyelid coloboma with facial deformities and cryptophthalmos could be considered as one anomaly.3

Nouby suggested a new grading for this anomaly, as follows3 :

  • Grade 1 - Coloboma without cryptophthalmos
  • Grade 2 - Coloboma with abortive cryptophthalmos
  • Grade 3 - Coloboma with complete cryptophthalmos
  • Grade 4 - Classic cryptophthalmos (absence of all eyelid structures and complete coverage of eye by skin)
  • Grade 5 - Severe cryptophthalmos (with severe deformity of the nose and ectropion of the upper lip)

Frequency

United States

An eyelid coloboma is a rare anomaly.

International

Manitoba Oculotrichoanal (MOTA) syndrome occurs in Aboriginal patients of the IslandLake region of Northern Manitoba. Characteristic findings in patients who are affected include unilateral upper eyelid coloboma or cryptophthalmos with ipsilateral aberrant anterior hairline pattern and anal anomalies.1,4

Mortality/Morbidity

Untreated eyelid colobomas may lead to significant morbidity.

Race

No known racial predilection exists.

Sex

No known sexual predilection exists.

Age

By definition, congenital eyelid colobomas are present at birth.

Clinical

History

  • Perinatal and pregnancy history
  • Family history of congenital eyelid colobomas or other congenital anomalies, especially facial (eg, cleft lip/palate)
  • History of other current birth defects
  • Pediatric review of systems
  • History of progressive corneal problems

Physical

Perform a complete ophthalmic assessment, possibly under general anesthesia or at the time of surgical repair. Possible associated findings include the following:

  • Choroid - Coloboma
  • Conjunctiva
    • Symblepharon
    • Malformation of the caruncle
    • Symblepharon from the defect to the globe
  • Cornea
    • Exposure keratopathy
    • Opacities
    • Cicatrization
  • Eyelids
    • Trichiasis
    • Dermoid tumors
    • Dermolipomas
  • Lacrimal system - Obstruction proximal to the lacrimal sac
  • Lens
    • Cataract (anterior polar)
    • Subluxation
  • Sclera - Epibulbar dermoid tumor
  • Eyebrows - Defects
  • Iris - Coloboma

Causes

An eyelid coloboma may occur either congenitally or as a result of trauma (eg, accidental, surgical).

Differential Diagnoses

Dermoid, Limbal
Duane Syndrome

Other Problems to Be Considered

Treacher Collins syndrome
Franceschetti syndrome
Oculoauricular dysplasia (Goldenhar syndrome)
Amniotic band syndrome
Cryptophthalmos syndrome (Fraser syndrome)
Manitoba Oculotrichoanal (MOTA) syndrome

Workup

Imaging Studies

  • CT scan of the orbits and the skull is indicated in patients with such associated syndromes as Treacher Collins syndrome.

Treatment

Medical Care

Corneal protection is the primary goal in the medical treatment of eyelid colobomas. Modalities that can be used either for small defects or for large defects awaiting definitive surgical therapy include the following:

  • Artificial tears and ointment
  • Moist chamber optical bandages
  • Bedtime patching

Surgical Care

Corneal protection and cosmesis are indications for surgical therapy. The surgical procedure used depends on the size and the location of the defect.

  • If the eyelid coloboma is small and well managed with topical lubrication, then surgery may be delayed until later in childhood. Usually, it is corrected by direct closure. The edges of the defect are freshened with sharp incisions, and precise anastomosis is preformed. The lid margin is brought together using a 2-layer approximation of the tarsus and the skin. Lateral cantholysis and placement of near-far, far-near sutures may be necessary to minimize horizontal tension.
  • If the eyelid coloboma is large, immediate surgical closure is usually needed to prevent corneal compromise. A 2-stage reconstruction may be required for those defects that occupy greater than 40-50% of the lid. The surgical procedure used depends on the involved lid.
    • Lower lid: The modified Hughes procedure is as follows: upper lid tarso-conjunctival flap (for tarsus layer) with retroauricular skin flap (for skin layer).
    • Upper lid: The modified Cutler-Beard procedure is as follows: lower lid tarso-conjunctival flap (for tarsus layer) with retroauricular skin flap (for skin layer).
    • Alternate techniques for either the upper lid or the lower lid include the following: a semicircular flap from the lateral canthal area (Tenzel or modified Tenzel flap) and a full-thickness lid rotational flap.

Consultations

  • Pediatrician and/or neonatologist
  • Genetics

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Ophthalmic lubricants

Prevent excessive dryness and irritation of the eye.


Artificial tears (Refresh Tears, GenTeal)

Acts to stabilize and thicken precorneal tear film and prolong tear film breakup time, which occurs with dry eye states.

Dosing

Adult

1-2 gtt OU

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Hyperemia, photophobia, stickiness of eyelashes, and ocular discomfort or irritation may occur

Follow-up

Further Outpatient Care

  • Perform corneal examination with staining to ensure that corneal abrasion from sutures is not present and to monitor corneal health or recovery from previous compromise.
  • Ensure that other coexisting anomalies have been ruled out and that all consultations have been performed.
  • Monitor patients closely for amblyopia, and treat this condition if necessary.

Inpatient & Outpatient Medications

  • Topical antibiotic or combination ointment, such as TobraDex, should be administered to the operated eye(s) 4 times a day for 1-2 weeks following surgery.

Complications

  • Amblyopia is the most common complication of any pediatric ocular problem. It must be ruled out and, if present, treated.
  • Eyelid-sharing procedures, such as the Hughes procedure and the Cutler-Beard (unmodified) procedure, should be used with caution (or not at all) in the pediatric population.
  • Planned excision of associated limbal dermoids should be cautiously undertaken. Pseudopterygium and symblepharon, as well as perforation, are common complications. Lamellar grafts have been advocated.
  • For lower lid colobomas, consider the mandibulofacial dysostosis syndromes, especially Treacher Collins syndrome or Franceschetti syndrome. Treacher Collins syndrome is associated with mandibular hypoplasia, which is a consistent feature of mandibulofacial dysostosis.
  • For upper lid colobomas, consider oculoauricular dysplasia (Goldenhar syndrome).
  • Amniotic band syndrome often presents with corneal opacities and facial clefts, in addition to eyelid colobomas.

Prognosis

  • Prognosis is excellent to good depending on the size of the lesion and the speed of therapy.

Patient Education

  • Genetic consultation is highly recommended, especially for patients with associated syndromes, such as Treacher Collins syndrome, which is autosomal dominant with variable penetrance and expressivity.

Miscellaneous

Medicolegal Pitfalls

  • Amblyopia as a result of using a lid-sharing procedure is a medicolegal pitfall.

References

  1. Li C, Marles SL, Greenberg CR, Chodirker BN, van de Kamp J, Slavotinek A. Manitoba Oculotrichoanal (MOTA) syndrome: report of eight new cases. Am J Med Genet A. Apr 15 2007;143(8):853-7. [Medline].

  2. Dibben K, Rabinowitz YS, Shorr N, Graham JM Jr. Surgical correction of incomplete cryptophthalmos in Fraser syndrome. Am J Ophthalmol. Jul 1997;124(1):107-9. [Medline].

  3. Nouby G. Congenital upper eyelid coloboma and cryptophthalmos. Ophthal Plast Reconstr Surg. Sep 2002;18(5):373-7. [Medline].

  4. Marles SL, Greenberg CR, Persaud TV, Shuckett EP, Chudley AE. New familial syndrome of unilateral upper eyelid coloboma, aberrant anterior hairline pattern, and anal anomalies in Manitoba Indians. Am J Med Genet. Apr 1 1992;42(6):793-9. [Medline].

  5. Agashe AP, Adrianwala SD, Bhatti SS, Contractor CP. Fraser's syndrome. J Postgrad Med. Oct-Dec 1992;38(4):209-10, 208. [Medline].

  6. Ankola PA, Abdel-Azim H. Congenital bilateral upper eyelid coloboma. J Perinatol. Mar 2003;23(2):166-7. [Medline].

  7. Budenz DL, Beyer-Machule CK, Albert DM. Histology of partial thickness double composite eyelid graft. Ophthalmic Surg. May 1989;20(5):362-6. [Medline].

  8. Collin JR. Congenital upper lid coloboma. Aust N Z J Ophthalmol. Nov 1986;14(4):313-7. [Medline].

  9. Crawford JS. Congenital eyelid anomalies in children. J Pediatr Ophthalmol Strabismus. Jul-Aug 1984;21(4):140-9. [Medline].

  10. Cuttone JM, Durso F, Miller M, Evans LS. The relationship between soft tissue anomalies around the orbit and globe and astigmatic refractive errors: a preliminary report. J Pediatr Ophthalmol Strabismus. Jan-Feb 1980;17(1):29-36. [Medline].

  11. Fuente del Campo A, Nahas R, Vazquez Ambriz V. A procedure for the reconstruction of the lateral palpebral canthus. Ophthal Plast Reconstr Surg. Mar 1994;10(1):6-10. [Medline].

  12. Hauben DJ, Tessler Z. One-stage reconstruction of a large upper lid defect in a newborn. Plast Reconstr Surg. Feb 1989;83(2):337-40. [Medline].

  13. Mansour AM, Barber JC, Reinecke RD, Wang FM. Ocular choristomas. Surv Ophthalmol. Mar-Apr 1989;33(5):339-58. [Medline].

  14. Mansour AM, Wang F, Henkind P, Goldberg R, Shprintzen R. Ocular findings in the facioauriculovertebral sequence (Goldenhar-Gorlin syndrome). Am J Ophthalmol. Oct 15 1985;100(4):555-9. [Medline].

  15. Patipa M, Wilkins RB, Guelzow KW. Surgical management of congenital eyelid coloboma. Ophthalmic Surg. Mar 1982;13(3):212-6. [Medline].

  16. Putterman AM. Wedge resection of eyelid margin in the treatment of abnormal eyelid margins. Arch Ophthalmol. Nov 1995;113(11):1458-9. [Medline].

  17. Roddi R, Vaandrager JM, van der Meulen JC. Treacher Collins syndrome: early surgical treatment of orbitomalar malformations. J Craniofac Surg. May 1995;6(3):211-7. [Medline].

  18. Sharma A, Sukhija J, Das A, Saroha V, Sukhi S, Mohan K. Large pedunculated congenital corneal dermoid in association with eyelid coloboma. J Pediatr Ophthalmol Strabismus. Jan-Feb 2004;41(1):53-5. [Medline].

  19. Yeo LM, Willshaw HE. Large congenital upper lid coloboma--successful delayed conservative management. J Pediatr Ophthalmol Strabismus. May-Jun 1997;34(3):190-2. [Medline].

Keywords

eyelid defects, congenital eyelid defects, Treacher Collins syndrome, mandibulofacial dysostosis, cryptophthalmos, facial deformity

Contributor Information and Disclosures

Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Jorge G Camara, MD, Chairman, Department of Ophthalmology and Otorhinolaryngology, Director of Fellowship Training Program, St Francis Medical Center; Associate Professor, Department of Surgery, University of Hawaii School of Medicine
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

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