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Ptosis (Pediatric)

What is Ptosis?

Ptosis (pronounced “toe-sis”) refers to a drooping of the upper eyelid. The eyelid may droop only slightly or it may droop enough to partially or completely cover the pupil, restricting or obscuring the field of vision. Ptosis may be inherited, can affect one or both eyelids and may be present at birth or occur later in life. Ptosis present at birth is called Congenital Ptosis. If the ptosis develops with age it is referred to as Acquired Ptosis.

What Causes Congenital Ptosis?

Congenital ptosis is most often due to an under-development of the eyelid lifting muscle – “the levator muscle”. Although usually occurring as an isolated problem, children born with ptosis may also have eye movement abnormalities, muscular disease, eyelid tumors or neurological disorders. Congenital ptosis does not improve with time unless it was caused traumatically at the time of birth.

What are the Signs and Symptoms of Congenital Ptosis?

Children with ptosis will often tilt their heads back into a chin-up posture to see below their eyelids. Patients with ptosis also may raise their eyebrows in an effort to raise their eyelids. When the eyelid droop is bilateral and severe, a child may bump into things and have delayed development as a result of the drooping eyelids causing some visual restriction.

What Problems Can Occur As A Result of Childhood Ptosis?

If the eyelid covers a part of the visual axis, the child’s visual development can be affected leading to a condition called amblyopia. Amblyopia is poor vision in an eye due to failure to develop normal sight in an eye during the early years (< 8 years old) of life. This may occur in a child with ptosis if the eyelid is drooping severely enough to block vision or cause astigmatism (abnormal curvature of the cornea). Ptosis may also hide a misalignment or crossing of the eyes which can also cause amblyopia. If not treated early in childhood the child’s vision will be permanently reduced as a result. As children enter formal schooling (pre-K or kindergarten), they may confronted by their peers about their droopy eyelids or asymmetric appearance. For many children these encounters are an unwanted, additional stress during a difficult time of separation from their parents and families.

How Is Congenital Ptosis Treated?

The treatment of congenital ptosis is surgical in the overwhelmingly majority of patients. In determining whether surgery is advisable, an ophthalmic surgeon specializing in treating droopy eyelids considers the individual’s age, the severity of the ptosis and whether one or both eyelids are involved. Measurement of the eyelid height, evaluation of the eyelids lifting and closing muscle strength, and observation of the eye movements help determine which surgical procedure is most appropriate.

The most common procedure involves advancing the under-developed levator muscle while the child is under general anesthesia. This is similar to the technique used to correct the most common form of ptosis (senile, aponeurotic) in adults. If the levator muscle has little or no function, the eyelid must be suspended to the brow so that the forehead muscle can do the lifting (Brow Suspension or Frontalis Sling). If this method of ptosis correction is indicated, Dr. Klapper or Dr. Bacorn will review with you the advantages and disadvantages of currently available sling materials.

Incisions are typically placed within the natural creases of the eyelids and are well hidden once the healing process is completed. The eyelid crease position or appearance may be abnormal in patients with congenital ptosis. This asymmetric appearance may persist following eyelid surgery. Frontalis sling incisions are made in the brow and forehead and are more visible than eyelid incisions.

After Ptosis Surgery

After surgery, the parents should expect their child to temporarily experience minor discomfort, as well as swelling and bruising of the eyelids. The eyelid blink rate is diminished for several weeks following surgery and the eyelids may not close completely leaving the eyes somewhat dry. Artificial tears during the day and a lubricating ointment at night are required to keep the eyes lubricated during the healing process. As the incisions heal and the eyelid mobility returns to normal, these dry eye symptoms usually resolve.

Blurry vision may occur during the healing period as a result of the decreased eyelid blink rate and/or ointment getting into the eye but should return to normal in 3 to 4 weeks or once eyelid closure improves and the supplemental lubricating eye ointment is required less frequently.

Unlike adults where eyelid height adjustments are made during surgery under local anesthesia, ptosis repair in children is performed under general anesthesia. It is therefore not possible to adjust the eyelid position with the child sitting up during the surgery. Therefore, the possibility that the eyelid may be under- or overcorrected is greater in pediatric cases than generally experienced in adult ptosis. Some children may require a touch-up procedure to adjust eyelid height in the first few weeks after surgery. Occasionally, once the healing process has settled (at around 3 to 4 months), eyelid asymmetry requiring further touchup procedures may be necessary. Excessive or prolonged swelling may affect the final position of the eyelid(s). Additional surgical procedures may be necessary to correct redundant or excessive eyelid or conjunctival tissue resulting from prolonged swelling.

Complications

Infection after eyelid surgery occurs in less than 1% of patients and usually responds to antibiotic therapy. All surgical patients undergoingskin incisions experience some scar formation.  Excessive scarring in the eyelid is unusual. Loss of vision following surgery has been reported but fortunately is extremely rare. It may occur if deep orbital hemorrhage occurs postoperatively.