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Grand Rounds Conference
Reema Syed, MBBS
University of Louisville
Department of Ophthalmology and Visual Sciences
October 3, 2014
Subjective
CC: “droopy right eyelid”
HPI: 7 month old male referred to Oculoplastics
clinic by Peds Ophthalmology for evaluation of
right upper lid ptosis. Ptosis was present since
birth, however, child was noted to have a
fixation preference for OS at his pediatric
ophthalmologist recently. Patching OS was
started for 1 hour/day
History
POH: ptosis OD
PMH: full term, uncomplicated vaginal delivery,
no birth trauma
Eye Meds: None, patching OS 1hr/day
Meds: none
Allergies: None
Family Hx: “lazy eye” (father)
Objective
OD
OS
VA (sc):
CS-UM
CSM
Pupils:
4 to 2 mm
4 to 2 mm
No anisocoria or RAPD
IOP:
15
15
EOM:
Full
Full
orthophoric in primary gaze
Cycloplegic refraction:
+1.00 +1.00 x90
+1.00 +1.00 x90
Objective
PLE:
Lids
OD
upper lid position
does not change
with feeding
No palpable masses
Eyelid crease
minimal
Palpebral fissure 5 mm
Marginal reflex 1 mm
distance - 1
Levator function 2-4 mm
OS
wnl
normal
9 mm
4 mm
10-12 mm
Objective
Conjunctiva/Sclera
Cornea
Anterior Chamber
Iris
Lens
Vitreous
ON
MVP
Normal OU
Clear OU
formed OU
Normal OU
No heterochromia
Clear OU
Normal OU
c/d 0.2, sharp and pink OU
Normal OU
Assessment

7 month old M with upper lid ptosis and poor levator function
OD, without any other ocular or systemic anomalies who has
recently developed amblyopia OD
DDx:
- Isolated unilateral congenital ptosis
- Marcus Gunn jaw winking syndrome
- Blepharophimosis syndrome
- Congenital third nerve palsy
- Congenital Horner's syndrome
- Congenital fibrosis of extra-ocular muscles
- Upper eyelid mass (neurofibroma, dermoid cyst)
- Pseudo-ptosis

Congenital Ptosis
•
Caused by maldevelopment of levator palpebrae
superioris due to abnormal innervation
•
normal muscle tissue replaced by fibrous and fatty
tissue
•
Characterized by decreased levator function, lid lag,
lagophthalmos
-
May be sporadic or familial (gene unknown)
-
Strabismus 30%, anisometropia 12%, amblyopia 20%
-
2/3 unilateral, 1/3 bilateral – may be asymmetric
-
Surgery usually delayed until 3-5 yrs of age unless:
-
Deprivational or anisometropic amblyopia
Ocular torticollis
Amount of upper lid excursion
Levator function
11 mm or more
Normal
8-10 mm
Good
5-7 mm
Fair
4 mm or less
Poor
Treatment Options
- Levator resection:
- used when levator function is good
- amount of upper eyelid excursion used to
determine the amount of muscle to be resected
* Smith B, Della Rocca R, Nesi F. Ophthalmic Plastic and Reconstructive Surgery. Vol 1. Philadelphia: CV Mosby,
1987:Fig. 30-27
-Frontalis suspension:
-used when absent or poor levator function
-most commonly used for congenital ptosis
-eyelid suspended directly from the frontalis so that
movement of the brow can be used to elevate the eyelid
*Amato M , Monheit B and Shore J. Ptosis surgery. Volume 5, Chapter 78, fig 13
Choice of sling
material
Advantages
Disadvantages
Autogenous Fascia Lata
- Gold standard
- Excellent tensile strength
- Best long-term results
- Recurrence unlikely
- Need for another surgical site
- increased risk of infection
- Minimum age 3 yrs
Allogenic Fascia Lata
- any age
- Second donor site not
required
- Small chance of rejection
- transmission of infection from
donor to recipient
Supramid
- any age
- Second donor site not
required
- High chance of recurrence due
to degradation of sling material
Silicone
- Not associated with
recurrence
- Can be adjusted intra and
post-operatively to adjust lid
margin height over time
Complications
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Under/over correction
Asymmetric eyelid contour
Scarring
Wound dehiscence
Eyelid crease asymmetry
Lagophthalmos with exposure keratitis
Back to our patient

Underwent silicone rod frontalis suspension OD
1 week post-op
• Retrospective chart review of 4 patients with ocular torticollis due to bilateral
congenital or acquired ptosis who underwent surgical correction
• pre and post operative systemic symptoms in 1 adult and developmental milestones
in 3 children are described
• Adult patient: 62 yr M with history of severe bilateral ptosis for 10 yrs presented to
his PCP with debilitating upper back pain for 3 yrs. Pain persisted despite multiple
referrals and therapies. Abnormal head posture due to ptosis found on ophthalmic
exam. Pain began to resolve within a week of surgical correction of ptosis
• Children: 12m , 10m, 5m olds with bilateral ptosis and development of head-tilt,
chin up position. No amblyopia but severe delays in gross motor development
without delay in any other milestones. Caught-up with motor milestones within a
few months of corrective surgery
References
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BCSC Orbit, Eyelids and Lacrimal System
BCSC Pediatric Ophthalmology and Strabismus
Smith B, Della Rocca R, Nesi F. Ophthalmic Plastic and Reconstructive Surgery
Amato M , Monheit B and Shore J. Ptosis surgery
Loff HJ et al. transconjunctival frontalis suspension: a clinical evaluation. Ophthal Plast Reconstr
Surg. 1999; 15(5): 349-354.
Baroody M et al. Advances in the diagnosis and treatment of ptosis. Curr Opin Ophthal. 2005;
16(6):351-355
Lee M, et al. Frontalis Sling Operation using silicone rod compared with preserved fascia lata for
cogenital ptosis. Ophthalmology 2009; 116(1) 123-129.
Thank you