Dr. Kahana has a particular passion for oculoplastic conditions that affect children. Children are not “little adults,” and require a unique approach with specialized skills and tools. Dr. Kahana has extensive experience with pediatric oculoplastic disorders, a result of his deep interest in the topic and years of academic research on the developmental biology of the eye and associated structures. Dr. Kahana has authored numerous manuscripts on the topic of pediatric oculoplastic surgery, taught courses, developed novel techniques, and advanced the science of pediatric oculoplastic surgery. Patients seek out Dr. Kahana from throughout the United States, traveling from afar for care, because of his unique expertise.

The upper eyelid needs to open sufficiently wide in order to clear the visual axis (i.e. clearing the pupil). Weakness of the muscle opening the eyelid (levator palpebrae superioris, or “levator”) can cause a droopy eyelid (“ptosis”) that covers the pupil. This can affect both eyes (“bilateral”) or just one eye (“unilateral”). When the child needs to raise their chin in order to see from under the eyelid, that is called “ocular torticollis,” which can harm the neck and back muscles and interfere with gross motor development. When the child has unilateral ptosis, the covered eye may be ignored by the brain, resulting in neurologic vision loss, or “amblyopia.”

Correcting ptosis can be done at any age, but the only reason to perform surgery in a very young child is to avoid vision loss or developmental delay. Otherwise, the surgery can wait until the child is at school age.

Surgery to correct ptosis may involve tightening the weak levator muscle, removing congenitally thickened connective tissue from around the muscle, or bypassing the muscle and connecting the eyelid directly to the forehead muscle (“frontalis”) so that the eyelid opens when the brow is elevated. Each of these procedures can be performed via a variety of techniques. Dr. Kahana has experience with all modern techniques.

Whenever possible, he prefers to remove abnormal connective tissue and tighten the levator muscle in order to give it a chance to regain function. Approximately 50% of patients who are predicted to have minimal levator function end up having reasonable function following surgery.

Sometimes, when the levator muscle is particularly weak, Dr. Kahana will also perform a frontalis muscle reanimation technique, in which a vascular flap of frontalis muscle is recruited into the eyelid so that the eyelid moves with brow movement. Some people refer to the technique as “frontalis sling,” although Dr. Kahana usually avoids the use of a formal sling material, preferring the more biological approach of frontalis muscle reanimation. There are many advantages to the reanimation technique, including avoidance of an implant and associated complications, and the reduced need for “redo” surgeries when the implant fails. However, there are situations in which Dr. Kahana will use a traditional frontalis sling, such as when the health of the patient necessitates minimal surgical time.

Congenital in-turning of the eyelid margins and lashes in a child is a type of entropion called “epiblepharon.” It is particularly prevalent in children of East Asian descent, but can occur in a child of any ethnicity. The correction involves removing a thin strip of skin and muscle and tucking the remaining muscle to the tarsal plate to prevent lid margin rotation towards the eye.
In some children, the nasolacrimal duct undergoes incomplete development – from an imperforate valve of Hasner – a very common problem – to a dead-end bony canal associated with conditions such as Down Syndrome. Some patients are born without a punctum or canaliculus. Treatment requires a correct diagnosis and then addressing the underlying anatomic issue. Dr. Kahana has performed hundreds of procedures to address pediatric tearing, including dozens of dacryocystorhinostomy surgeries – a procedure that is particularly challenging in a child, and with which Dr. Kahana has a high rate of success.
During embryonic development, stem cells migrate throughout the body, and particularly to form the head and face. On occasion, a small number of cells get “stuck” in one of the bony sutures of the face, developing into a cyst. These cysts are called “dermoid” cysts, and the often occur around the eye. The most common location is just under the tail of the brow, but they can occur in other locations as well. Dermoid cysts can rupture, causing significant localized scarring and pain. A surgical excision can eliminate the issue, usually with a small incision that heals with minimal scarring.
Children can suffer from a variety of tumors and masses, just like adults. However, the tumor types are often quite different. Children can have orbital dermoid cysts, vascular anomalies, tarsal and lacrimal cysts, traumatic foreign bodies, inflammatory conditions, infections, and cancerous growths. Dr. Kahana has extensive experience with all these entities, and will be able to provide a treatment plan based on his findings.
Blepharophimosis Syndrome, which consists of congenital ptosis, narrosing of the horizontal palpebral fissure, folds of the inner canthus, and sometimes outward turning of the lower eyelid margins laterally (euryblepharon). There is a page on this site dedicated to blepharophimosis Syndrome (also known as “BPES”). Dr. Kahana is a pioneer in the treatment of BPES, with unique skills and expertise gained over many years of caring for the smallest and most challenging patients.

These are before/after photos of a young boy with blepharophimosis syndrome. The severity of his ptosis threatened his visual development. He underwent ptosis repair surgery, including frontalis muscle flap reanimation and levator advancement, and now he can see. The results have been stable since 2019.