CONGENITAL PTOSIS

Congenital ptosis: ptosis present from birth. It is a problem that can affect one or both eyes. Ptosis may be mild, in which case the eyelid partially occludes the pupil, or it may be severe, occluding the pupil completely. Children with ptosis may tend to tilt their head back or exaggeratedly raise their eyebrows in order to see under the eyelids. The most common cause of congenital ptosis is incomplete development of the levator muscle of the eyelid. This muscle is primarily responsible for lifting the eyelid. Children with congenital ptosis may also have amblyopia (lack of vision development), strabismus (crossed eyes) or blurred vision due to astigmatism.

CONGENITAL PTOSIS TREATMENT

Congenital ptosis is treated with surgery. The type of operation needed will depend on the degree of ptosis and the strength of the levator muscle. If the ptosis is not severe, surgery is generally preferred after the child is 4 years old. However, if it interferes with vision, surgery should be performed early to allow for normal vision development.

CAUSES OF CONGENITAL PTOSIS

Ptosis may occur in isolation, without other disorders. There are hereditary cases that are associated with folds on the inner side of the eyes (epicanthus inversus) and constitute the so-called congenital eyelid syndrome or blepharophimosis. The two most commonly used techniques are levator resection and ptosis surgery with frontalis suspension.

LEVATOR RESECTION

It is used in patients with good or regular muscle function, and it involves shortening the affected muscle to give it more lifting power. If the muscle does not work properly, this technique carries the risk of not allowing the eye to close completely. That is why it is very important to evaluate each case in order to choose the most favorable technique. Dr. Devoto is one of the authors of a paper published in the United States, which describes the supramaximal levator resection ptosis surgery technique: Cruz AA; Akaishi P; Mendonça A; Bernadini F; Devoto M; Garcia D. Supramaximal Levator Resection for Unilateral Congenital Ptosis: Cosmetic and Functional Results. Ophthalmic Plastic & Reconstructive Surgery 2014 – Volume 30 – Issue 5 – p 366–371.

FRONTALIS SUSPENSION PTOSIS SURGERY

This technique is used in patients with poor or no levator muscle function. This procedure replaces the function of the eyelid levator muscle with the lifting action produced by the eyebrow. It is very common for people who do not lift their eyelids properly to compensate by raising their eyebrows. In frontalis suspension surgery, the eyebrow on the affected side is attached to the eyelid in order to lift the eyelids by raising the eyebrows, allowing the eyelids to close properly.
How likely is it that more than one surgery will be necessary?
In children, where the muscle is shortened, it is a matter of estimating the necessary height based on the degree of function and previous height. Unfortunately, it is not possible to adjust the height during the operation as it is done in adults, since the child cannot cooperate and general anesthesia is required. This leads to adjustments being made in 15 % to 20 % of patients. When the suspension technique is used, the incidence of reoperation is lower.
The most important goal in congenital ptosis repair is to support the child’s visual and social development. This is achieved if the eyelids are brought to a normal height. Occasionally, some children may require reintervention when they reach adolescence to maximize esthetics in case of asymmetry.
Fortunately, this is rare. Sports or trauma should be avoided for the first month after surgery, but after that period, children can lead a normal life, including taking part in all sports.

BEFORE AND AFTER

case 1

BEFORE:

Patient with right congenital ptosis. Right upper eyelid supramaximal levator resection surgery was performed.

after:

Postoperative with adequate symmetry.

case 2

BEFORE:

Patient before surgery.

after:

Patient’s postoperative selfie.
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