Services for Children

Congenital Ptosis

Congenital ptosis occurs because of abnormal development of the muscle that lifts the eyelid (levator palpebralis).  This can be associated with certain syndromes.    One of the hallmarks of congenital ptosis is that the affected lid does not come all the way down when a child looks down—it “lags” behind the normal lid (lid lag).    Also, the upper eyelid crease is not usually as well defined in people with congenital ptosis -- the ptotic lid is relatively "smooth" when compared to the normal one.

Neurologic Ptosis

All muscles in the body “do as they are told” by the nerve that supplies them with information from the brain.   This applies to the muscles that move the eye (extraocular muscles) and those that lift the eyelid (levator and Muller muscles).  If a neurologic insult has occurred to the nerve supply of the levator – and ptosis results – this will typically (but not always) be accompanied by abnormal function of the pupil (it becomes larger) and some of the extraocular muscles.  

In addition to nerve impairment causing ptosis (plus variable degrees of strabismus and pupil abnormality), there can be chemical abnormalities at the junction between the nerve and the levator (myasthenia gravis).  Myasthenia gravis is rare in childhood but needs to be considered.   

Timing of surgery

Ptosis can cause amblyopia if the lid completely covers the pupil.  In these cases, the ptosis must be repaired as soon as possible so as to prevent worsening of amblyopia and allow for its treatment.  Another indication for surgery is if the ptosis is causing high astigmatism (which will produce amblyopia).  Finally, if a child is lifting her chin all of the time she should have her ptosis repaired without significant delay – the abnormal head position (torticollis) is assumed so that she can use both eyes together and see things three-dimensionally.

If the ptosis is not severe enough to cause amblyopia, there is nothing wrong with waiting until a child is 4 or 5 years old before surgical repair.  Children younger than this are don’t typically notice their different appearance and are unlikely to be teased by other children, but it is acceptable to do surgery at younger ages if the parents so desire.

Surgery

There are two major methods for repairing ptosis: tightening the levator (or Muller’s muscle) or lifting the lid mechanically.   To “tighten” the levator an incision is usually made on the skin of the eyelid; to operate on Muller’s muscle the incision is made on the undersurface of the eyelid.  There are indications and benefits (and risks) to each of these approaches, and each case needs to be determined individually.  In general, my preference is to operate on Muller’s muscle if pre-operative evaluation predicts a favorable outcome.

Lifting the eyelid mechanically involves placing material under the skin, just in front of the skull, to suspend and hold the lid in place.   There are many different materials used and every one of them has worked well, and failed, at some time.  Synthetic materials are most commonly used but we can also use tissue harvested from a person who has died and made a gift of tissue from their thigh (fascia lata); fascia lata is tested for all known transmissible diseases and then irradiated – over many years there have been no reported cases of disease transmission.  

The greatest risk of surgery is the need for reoperation.  Everybody heals differently.  While some children require just one surgical repair – and this is what everyone involved would like – some children do need another operation (or operations) in the future.   It is impossible to predict who will need more than one surgery or the interval between surgeries.  Basically, most children need just one repair and some need several.  

There is a risk of infection, though this is uncommon.  A very aggressive infection could cause vision loss or systemic infection, but this is very, very rare.  To minimize infection risk, antibiotic drops or ointments are used after surgery for the first week or so, and the patient is examined during the first week after surgery (when the risk of infection is greatest).

Just after surgery the eyelid will often be higher than its final position.  This can cause dryness of the eyeball, especially when the patient is sleeping, so it is very important to keep the eye lubricated in the immediate post-operative period.  As noted above, people with congenital ptosis have a problem with the lid coming down normally, as well – you might have noticed that the eye with ptosis appears open when your child sleeps.  All ptosis repair techniques have a tendency to exacerbate this inability to close the lid – this will be noticeable when the patient is asleep and especially when she looks; this is particularly the case when a suspension procedure is performed.   A slightly abnormal appearance some of the time after surgery is considered by most parents – and nearly all pediatric ophthalmologists – to be a good trade  when weighed against the risk of permanent vision loss, abnormal head position, or an abnormal appearance all of the time that results from not doing surgery.