Congenital Ptosis

WHAT IS A DROOPY EYELID OR PTOSIS?

A drooping eyelid or ptosis can be present at birth (congenital) or can occur later in life (acquired). Poor development of the muscle that lifts the upper eyelid (levator muscle) is the most common cause of congenital ptosis. Ptosis can involve one or both upper eyelids.

WHAT PROBLEMS CAN OCCUR AS A RESULT OF CHILDHOOD PTOSIS?

The following abnormalities may accompany ptosis in childhood: Obstruction of the visual axis (the path that light takes into the eye) may lead to amblyopia (delayed development of the visual system). A chin-up head position: this head position is adopted in order to be able to see beneath the edge of the drooping upper eyelid.

HOW IS PTOSIS TREATED?

Treatment of congenital ptosis is surgical. Children are usually monitored regularly for vision abnormalities. Surgery may also be indicated during preschool years if the ptosis does not improve with normal growth and maturation of the face, especially if there is vision loss, a large abnormal compensatory head position, or social stigma.

SURGERY FOR CONGENITAL PTOSIS

The method of repair depends on treatment goals, the underlying diagnosis, and the degree of levator function. Although the primary reason for the repair is functional, the surgeon may be able to improve symmetry in lid height, contour, and eyelid crease.

Surgical correction of congenital ptosis can be undertaken at any age depending on the severity of the disease. Earlier intervention may be required if significant amblyopia or abnormal head position is present. If intervention is not urgent, surgery is often delayed until age 4-5 years. Waiting until this age allows for more accurate measurements preoperatively.

Levator muscle tightening

This procedure is used when ther is moderate levator function. The levator muscle is shortened to lift the eyelid. The skin incision is hidden either in the existing lid fold or in a new lid fold created to match that of the contralateral eyelid. In some patients the procedure is perfromed from inside the eyelid.

Contraindications include poor Bell phenomenon (limited elevation of the eye), reduced corneal sensitivity, or poor tear production.

Frontalis suspension procedure

This procedure is used when there is little on no levator function. The eyelid is connected to the eyebrow using a variety of materials to create a brow suspension: the eyelid opening is augmented by elevating the eyebrow.

Frontalis suspension procedures produce lagophthalmos (inability to close eye completely) in all cases.

Relative contraindications include a Poor Bell phenomenon (limited elevation of the eye), reduced corneal sensitivity, or poor tear production can produce exposure keratopathy.

Materials used to create a brow suspension:

• Autogenous fascia lata: Autogenous fascia lata can be obtained from the leg of patients older than 4 years.
• Preserved (tissue bank) fascia lata
• Nonabsorbable suture material (eg, 2-0 Prolene, Nylon (Supramid) or Mersilene)
• Silicone bands, silicone rods
• ePTFE (expanded Poly Tetra Fluoro Ethylene), Gore-Tex

NOTE: Patients will not be able to close their eyelids during sleep following surgery. The problem of open lids during sleep improves with time; however, aggressive lubrication is needed to avoid exposure keratopathy.

SURGICAL FOLLOW UP

Regular follow up is necessary in the first few weeks following surgery to make sure that the wound is healing well and surface of the eye is adequately lubricated

COMPLICATIONS

• Complications associated with the frontalis suspension procedure for congenital ptosis repair include the following:
• Granuloma: This is a localised are of inflammation in the area of operation. Granulomas should be treated conservatively because they tend to eventually resolve.
• Lid asymmetry
• Overcorrection with exposure keratopathy and dry eyes
• Undercorrection: Suspension materials may dissolve or break. Suture material may tear through soft tissue. Undercorrected congenital ptosis repair may require repeat surgery.
• Infection