Corneal-scleral fusion in children causes symptoms and treatment

Many parents are often surprised when they notice any change in their child’s eyes, especially if the eye looks different or there is adhesion between the cornea and the sclera. Corneoscleral adhesion in children is a rare but very important condition, as it can affect vision and the development of the eye. In this Dalili Medical article, we will cover everything about this condition: the causes, symptoms, types, stages of diagnosis, treatment options with medications and surgery, helpful exercises, and the most important tips for parents on how to properly care for their child and ensure the best medical follow-up.

What is Corneoscleral Adhesion?
It is a partial or complete adhesion between the cornea (the transparent part at the front of the eye) and the sclera (the white outer layer surrounding the eye). This adhesion can affect the shape of the eye and visual strength.

Is the Condition Serious?
Not all cases are serious, but if diagnosis or treatment is delayed, it can impact vision and may require surgical intervention.

Can the Child Live a Normal Life?
Yes, with early diagnosis and proper treatment, most children can live a very normal life, with regular follow-ups with a pediatric ophthalmologist.

Most Important Things Parents Should Do:

Regular follow-ups with a pediatric ophthalmologist.
Adherence to prescribed medications or exercises.
Providing psychological support and avoiding any embarrassment or bullying due to the eye’s appearance.

Can the Adhesion Appear Suddenly After Birth?
Usually, it is present from birth or during the first few months, but its appearance after the first year is very rare and requires urgent medical evaluation.

Can Corneoscleral Adhesion Cause Psychological Issues?
Yes, the different appearance of the eye may cause embarrassment or reduce the child’s self-confidence, especially if there is teasing from other children.

Do All Children Need Imaging or Tests?
Not all children, but in severe or complex cases, the doctor may recommend MRI or additional eye and brain tests.

Does Adhesion Affect Eye Growth?
Yes, if left untreated, it may affect eye shape, movement, and long-term vision.

Do Children Feel Pain?
Usually not, but they may experience eye strain or excessive tearing.

Does Treatment Require a Specialized Team?
Yes, it usually involves a pediatric ophthalmologist, a surgical specialist, and sometimes a vision therapist for exercises.

Types of Corneoscleral Adhesion in Children

1️⃣ Type I – Peters Anomaly

Cornea is partially or completely opaque.
Adhesion between cornea and sclera is limited and small.
Usually no lens problems or strabismus.

2️⃣ Type II – Peters Anomaly

Wider adhesion between cornea and sclera.
Often associated with lens problems (e.g., displaced or malformed lens).
Vision may be severely affected.

3️⃣ Combined / Complex Type

A mix of Type I and II.
Often associated with other eye defects such as anterior chamber angle anomalies, congenital glaucoma, or strabismus.

4️⃣ Syndromic Peters Anomaly

Part of congenital syndromes affecting the heart, kidneys, or nervous system.
Requires full systemic evaluation, not just the eyes.

Causes of Corneoscleral Adhesion in Children

Genetic and Congenital Causes:

Genetic disorders affecting eye development during pregnancy.
Sometimes associated with congenital syndromes like Axenfeld-Rieger syndrome.
Abnormal development of the cornea or its internal layers, such as Descemet’s membrane.

Other Eye-Related Issues:

Lens problems or anterior chamber angle abnormalities.
Can lead to congenital glaucoma.

Rare Acquired Causes After Birth:

Severe trauma or acute infections, but most cases are congenital.

Symptoms of Corneoscleral Adhesion in Children

Blurred or impaired vision: Difficulty focusing, partial visual loss.
Corneal opacity: Cloudy or opaque spots present from birth.
Light sensitivity (photophobia): Child may squint or turn away from light.
Excessive tearing or abnormal discharge: Due to corneal irritation or immaturity.
Abnormal eye appearance: Differences in size or shape; sometimes a smaller or asymmetrical eye.
Associated complications: Lens problems, anterior chamber anomalies, or congenital glaucoma.

Stages of Corneoscleral Adhesion in Children

1️⃣ Congenital Stage

Present from birth or within the first weeks of life.
Adhesion is mild with limited effect on vision, requiring close monitoring.

2️⃣ Progressive Adhesion Stage

Adhesion gradually increases.
Lens abnormalities or strabismus may appear, and vision may worsen if untreated.

3️⃣ Complex Stage

Adhesion covers a large portion of the cornea and sclera.
Often associated with lens deformities or abnormal anterior chamber angles and glaucoma.
Requires urgent surgical intervention to prevent complications.

4️⃣ Chronic/Advanced Stage

Adhesion is persistent without treatment.
Vision is severely impaired, with potential partial or total blindness.
Surgical intervention is more difficult and requires a specialized team with long-term follow-up.

Diagnosis of Corneoscleral Adhesion in Children

Clinical Eye Examination: Evaluate the cornea, sclera, and extent of adhesion; examine lens, anterior chamber, and cornea.
Visual Acuity Tests: Age-appropriate tests to assess focus and vision strength.
Ultrasound / B-Scan: Assess cornea, sclera, and lens, especially in severe adhesion.
Anterior Segment OCT: Provides precise imaging of corneal thickness and adhesion boundaries; important for surgical planning.
Intraocular Pressure Tests: Determine if the child is at risk of congenital glaucoma.
Genetic and Associated Tests: Identify if adhesion is linked to congenital syndromes; may include genetic testing or systemic evaluation.

Treatment of Corneoscleral Adhesion in Children with Medications

Anti-inflammatory eye drops

Used if there is inflammation due to adhesion or infection.
Examples: topical NSAIDs or corticosteroids, depending on the doctor’s prescription.
Goal: Reduce redness and swelling, and improve eye comfort.

Lubricating eye drops

Protect the cornea and reduce dryness or irritation caused by the adhesion.

Medications to prevent complications

Used to control eye pressure if adhesion may cause glaucoma.

Antibiotics if needed

Prescribed in case of secondary infection; adherence to dosage and duration is essential.

Important Tips for Using Medications:

All medications must be under strict medical supervision.
Regular follow-ups to monitor the effect of the medication on the cornea and vision.
Medication is usually part of a comprehensive plan that may include exercises or surgery if necessary.

Surgical Treatment of Corneoscleral Adhesion in Children

1. Anterior Adhesion Release

Indication: Limited adhesion between the cornea and anterior sclera.
Goal: Free the cornea, restore eye movement, and reduce eye pressure.
Method: Use precise instruments to separate the cornea from the sclera with saline or adhesion-dissolving agents.
Follow-up: Anti-inflammatory and lubricating eye drops post-surgery.

2. Angle Surgery

Indication: Narrow anterior chamber angle causing fluid drainage issues and high eye pressure.
Goal: Improve fluid drainage and prevent glaucoma.
Method: Open the drainage angle using precise techniques like trabeculotomy or goniotomy.
Follow-up: Monitor eye pressure and use preventive drops.

3. Partial Keratoplasty / Corneal Graft

Indication: Adhesion affects corneal transparency or causes scarring.
Goal: Restore clear vision and protect the eye.
Method: Remove the affected part or replace it with suitable corneal tissue.
Follow-up: Anti-inflammatory and antibiotic drops; careful monitoring to prevent graft rejection or re-adhesion.

4. Posterior Scleral Surgery

Indication: Adhesion extends to the posterior sclera or causes retinal issues or eye pressure problems.
Goal: Protect the retina and ensure normal eye fluid flow.
Method: Precise surgical intervention using a microscope, mechanical tools, or laser.
Follow-up: Monitor eye pressure and implement preventive treatments.

Important Post-Surgery Tips:

Regular follow-ups with a pediatric ophthalmologist.
Strict adherence to prescribed eye drops.
Watch for redness, pain, or vision deterioration.
Some children may need adjustments or additional surgeries as they grow.
Goal: Restore clear vision, protect the eye, and reduce the chance of adhesion recurrence.

Failure of Corneoscleral Adhesion Surgery in Children

Meaning of Surgery Failure:

The intended outcome is not achieved, e.g., persistent adhesion, poor vision, or high eye pressure.

Common Causes of Failure:

Re-adhesion after surgery due to rapid tissue healing in young children.
Postoperative infections causing scarring or fibrosis.
Problems with the anterior chamber angle or fluid drainage.
Corneal or scleral scars reducing transparency.
Complex congenital problems lowering the chance of full success.

Complications of Surgery Failure:

Partial or complete vision loss in severe cases.
Persistent or worsening glaucoma.
Need for repeat surgery or additional interventions.
Eye growth disturbances or strabismus due to ongoing adhesion.

Management of Surgery Failure:

Complete medical reevaluation: Examine cornea, sclera, and eye pressure; use imaging or OCT to assess remaining issues.
Repeat surgery or adjustments: Some children may need a second procedure or partial intervention to remove adhesion or clean corneal scars.
Supplementary medication: Anti-inflammatory drops, lubricants, and sometimes pressure-controlling drugs.
Continuous long-term follow-up: With a pediatric ophthalmologist and sometimes a neurologist to prevent future complications.
Vision exercises and psychological support: Improve visual focus, reduce eye strain post-surgery, and support the child psychologically to cope with vision challenges.

Exercises for Corneoscleral Adhesion in Children

Exercises help improve visual focus, strengthen the eyes, reduce eye strain, and support visual development after surgery or as a complementary treatment. They do not treat the adhesion itself but improve eye function.

1️⃣ Visual Focus Exercises

Goal: Train the eyes to focus on near and far objects.
Method: Use a small toy or ball. Have the child focus on it at a close distance for 10–15 seconds, then move it away to focus at a distance. Repeat 5–10 times daily.

2️⃣ Tracking Exercises

Goal: Improve the eye’s ability to follow moving objects and reduce eye jitter.
Method: Use a small light or slowly moving toy up-down or left-right. The child follows the movement with their eyes. Repeat 5–10 times daily.

3️⃣ Patch Therapy (Amblyopia Exercises)

Goal: Strengthen the weaker eye after surgery or in cases of reduced vision.
Method: Cover the stronger eye for specific periods as directed by the doctor, encouraging use of the weaker eye.

4️⃣ Magnifying Exercises

Goal: Improve visual precision and detail recognition.
Method: Use a magnifying glass or books with fine details. Have the child identify objects or read small letters daily according to their capacity.

5️⃣ Visual-Motor Coordination Exercises

Goal: Enhance eye-body coordination and balance.
Method: Simple activities like throwing a ball, stacking blocks, drawing on large sheets, maze games, or following shapes with the eyes.

⚠️ Important Notes:

Exercises are complementary to medical and surgical treatment, not a replacement.
Must be performed under supervision of a pediatric ophthalmologist or vision therapist.
Consistency is more important than quantity; a daily or near-daily schedule is recommended.
Primary goal: Improve eye performance, support visual focus, and reduce eye strain—not remove the adhesion itself.