Ptosis is a drooping of the upper eyelid. Ptosis can be present at birth (congenital ptosis) due to abnormal development of the muscle that lifts the eyelid, which can be hereditary. A droopy eyelid can cause blurring of vision or watering of the eye due the weight of the eyelid pressing on the front of the eye. If left untreated, a ptosis in a child can cause affect visual development with consequential amblyopia (lazy eye). It can also affect the superior field of vision causing patients to raise their eyebrows constantly (leading to headaches) or tipping their head back in an attempt to gain clear vision. It can become a cosmetic issue, affecting a childs self esteem and often children who get teased or bullied at school, seek early surgical correction.
How can childhood ptosis or droopy upper eyelid in children be treated?
If your child has a congenital ptosis, he/she will need visual monitoring to ensure that the ptosis is not adversely affecting their visual development. Once the ptosis starts occluding the visual axis, or affects visual development, it is treated by surgical correction. The aim of surgical correction is to restore the anatomy, by addressing the various causative factors. All ptosis surgery in children is performed under general anaesthesia. Generally ptosis surgery is deferred till the child is 1-2 years old, only being undertaken earlier if it is severe.
Surgical correction for droopy upper eyelid in children
The operations for childhood ptosis correction are generally based on the muscle function. If the levator muscle function is good, then a tightening of the tendon / muscle that lifts the eyelid is offered. The cut can be hidden within the inside of the eyelids resulting in scar less minimally invasive operation or it is hidden within the skin fold (thus hiding the scar). When the muscle function is poor, a strip of tissue from the thigh (called fascia lata) or a silicone band/ mersilene mesh is used to lift the eyelid by using the forehead muscle. Here the scars are hidden in the skin fold and there are 3 small scars on the forehead.
In certain type of unilateral ptosis with poor muscle function, or synkinesis syndromes like Marcus Gunn Jaw winking, the surgery performed has to improve symmetry and/or address the “wink” & often involves operating on the non affected or “good” side. Depending upon the cause of ptosis, surgery can range from a simple 30 minute procedure to a more complicated 90 minute procedure. Recovery times are generally quick, most patients achieving complete recovery within 14 days.
What are the potential risks & complication of ptosis surgical correction?
The risks of ptosis surgery include
- Infection: this is very rare, occasionally the stitches may have an infective or inflammatory response, which settles with oral and topical antibiotics.
- Scarring (generally hidden in the skin fold). Normally stitches are visible for the first week, and then when they are removed, a faint scar is visible. The scar may seem a bit thickened & red for 6 to 12 weeks, becoming almost invisible after that period. Not every scar heals equally well. A thickened or reddened scar can be improved with silicone scar remodeling gel, but the treatment needs to be continues for months to have a good result.
- Large bruise or haematoma. This is minimized by avoiding heavy exercise for 2 weeks after surgery, stopping aspirin and other anticoagulants (if safe so to do) 2 weeks pre operatively, and regular use of ice packs. A haematoma may mean you have to go back into theatre to have the blood clot evacuated and then be re-stitched with the risk of a worse scar.
- Theoretical risk to vision. Any eyelid surgery carries the risk that an undiagnosed infection or bleed could damage the optic nerve. This is so rare that in comparison a normal car journey is a much greater risk to your vision.
- Asymmetry of eyelid shape, height or upper lid fold: this is rare, but can occur. Often asymmetry may be due to lid bruising and settles spontaneously as swelling resolves. Rarely, this may require revision surgery. Occasionally pre existing asymmetry of the face, eyebrow or eyeball position, may be responsible, however this will be discussed with you prior to the operation by your surgeon.
- Poor blink, as the muscle that shuts the eyelid has been cut to access the muscle that lifts the eyelid. Generally blink returns to normal within 12 weeks.
- Incomplete eyelid closure / nocturnal lagophthalmos (eyelids staying a bit open when asleep) or lid lag (upper eyelid hangs up in down gaze). This is seen in congenital ptosis patients who undergo surgical correction. This is because the muscle that lifts the eyelid has not developed properly & so does not tighten (to lift the eyelid) and does not relax (to allow the eyelid to close). This side effect may warrant permanent use of lubricant drops and ointment, to keep the eye comfortable.
1. Child with congenital left upper lid ptosis, with 6mm levator function. The droopy eyelid is occluding visual axis and needs to be corrected to prevent development of ambylopia (lazy eye). 2. 1 week post surgical repair of left upper lid congenital ptosis with levator resection 3. 2 years post surgical repair of left congenital ptosis
1. Correction of congenital ptosis with resultant “Lagophthalmos” (incomplete eyelid closure) which is secondary to a dystrophic levator muscle that does not relax to allow eyelid closure. 2. Correction of congenital ptosis with resultant “Lid lag ” ( hang up of eyelid on down gaze) which is secondary to a dystrophic levator muscle that does not relax to allow eyelid movement. 3. Two years post surgical repair of left congenital ptosis
- Recurrence of ptosis: This can occur early post surgery (3 months) or late (after a few years), due to early suture dissolution or a weakening/stretching of the scar. This will need to be corrected by re-operation.
- Contralateral ptosis: The eyelids are a pair, and often when one eyelid is droopy, the contralateral eyelid can appear to be in a “normal” position. However, immediately after surgery, the “normal” eyelid can droop. This can correct itself within a few weeks or require a ptosis correction.
- Exposure of the material used to perform the sling, with resultant infections/granulomas. If this happens, the sling needs to be removed.
- Slippage of the sling – this can occur when using silicone. If this happens, the sling needs to be adjusted surgically.