Surgical Correction of Congenital Ptosis

Ptosis, also known as drooping eyelid, occurs when the upper eyelid does not open adequately. Ptosis in newborns is called congenital ptosis. It occurs when the muscle responsible for lifting the eyelid has fibrotic and atrophic features, and it lacks strength to lift the eyelid. This problem can affect one eye or both eyes. 

Ptosis can be mild in which case the eyelid has a slight asymmetry in height.  Occasionally, the eyelid can partially cover the pupil  and block the upper part of the visual field.  When the ptosis is severe, it obstructs a great amount or all of the visual field.  This situation is usually detected by the parents or a pediatrician at birth or during the first months after birth. The pediatrician serves as liaison with a pediatric ophthalmologist or with an ophthalmic plastic surgeon. 

Common Causes

The most common cause of congenital ptosis is incomplete development of the muscle that lifts the eyelid. This muscle is mainly responsible for lifting the eyelid. Children with congenital ptosis can have amblyopia or lack of visual development, strabismus (crossed eyes), or blurred vision due to astigmatism or change in the curvature of the cornea.   

Congenital ptosis is treated with surgery. The type of surgery required will depend on the degree of ptosis and the strength of the levator muscle.  When the ptosis is not severe, it is preferred to perform surgery during preschool years because the child will be able to cooperate in an important part of the surgical process, specifically help in measuring in millimeters how high the eyelid opens and the amount of movement it has. However, if the ptosis interferes with the child’s vision, the surgery should be performed at an early age to allow for normal visual development because the critical development period occurs during the first three months of the infant’s life. 

Before the surgery, the physician must determine the amount of movement in the eyelid and the difference in height between each eyelid. This process requires preciseness because these two measures will determine the how many millimeters will be cut from the eyelid. Because these measurements are so small, they must be taken with great precision. If the muscle function is moderate to excellent, the muscle will be shortened a predetermined amount during the surgery.  If muscle function is poor, the eyebrow will be used to lift the eyelid, creating a fixation between the eyelid and the eyebrow. Synthetic, homogenous or autogenous materials can be used to suspend the eyelid from the eyebrow. The autogenous method uses a strip of tendon obtained from the person’s thigh. The patient must be more than three years old to use the fascia or autogenous tendon. Longevity of synthetic material is less than the homogenous tissue that has less longevity than autogenous material.  When synthetic or homogenous materials loose effectiveness, a new surgery must be performed using tendon from the patient because it is the method that will provide the longest lasting effects and most natural appearance. 

The Recovery

This procedure is ambulatory and post-surgical care requires aggressive lubrication of the cornea and use of anti-inflammatory eye drops containing antibiotics. During the first week, the patient will remain at home with restricted time for outdoor activities to avoid exposing the patient to dust, dirt and sun. The patient can usually return to his or her normal activities within one to two weeks. 

Having congenital ptosis can greatly affect a person. In addition to the functional implications, droopy eyelids have a cosmetic impact because they give the face an undesirable expression and children are subject to teasing and bullying. This anomaly impacts the child for the rest of his or her life because it affects a highly visible part of the body – the face. These are additional considerations that favor corrective surgery early in the child’s life. An ophthalmologic plastic surgeon is the professional who should perform this surgery.