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  • Shaken Baby Syndrome

    Tuesday, 21 July 2015 16:28
  • Amniotic fluid problems

    Thursday, 14 May 2015 12:54
  • Choosing a pre-school

    Friday, 10 April 2015 17:50
  • Newborn reflexes

    Tuesday, 03 March 2015 15:49
  • Mastitis

    Tuesday, 03 March 2015 15:41
  • Pelvic floor exercises

    Wednesday, 11 February 2015 17:20
  • Colic

    Wednesday, 11 February 2015 17:11
  • Antenatal Classes

    Monday, 03 June 2013 09:34
  • Strap-in-the-Future

    Thursday, 30 June 2011 13:52

Congenital Ptosis

Congenital_PtosisA drooping eyelid is called ptosis or blepharoptosis. Ptosis can affect one (unilateral) or both eyelids (bilateral). In ptosis, the upper eyelid falls to a position that is lower than normal. The lid may droop slightly or severely enough to partially or completely cover the pupil, restricting or obscuring vision.

Ptosis may be inherited, can be present at birth or develop later in life. If the condition is present at birth or within the first year of life, it is called congenital ptosis. If the ptosis develops with age, it is referred to as acquired ptosis.

Although both types of ptosis can significantly affect cosmesis (the way the child looks) and interfere with visual function, congenital ptosis is particularly important due to its potential effects on visual development and maturation, proper ocular alignment, and psychosocial development. In most cases of congenital ptosis, the problem can be isolated and successfully treated with surgery to improve visual function and cosmetic appearance. Ophthalmic assessment is extremely important to avoid the development of amblyopia (poor vision due to "lazy eye").

Children with ptosis may have a droop of one or both eyelids and may appear sleepy looking. In congenital ptosis, there is often asymmetry of the upper eyelid creases. Children with the condition often tilt their heads back into a chin-up position in an effort to see, or raise their eyebrows as an attempt to raise their lids above the visual axis. These head and facial maneuvers are an indication that the child is trying to use both eyes to see. If the ptosis is left untreated, these abnormal head positions may result in abnormalities in the head and neck. In severe cases of bilateral ptosis, the infant may bump into things because their droopy eyelids are restricting their visual field. This may result in further developmental delays.

Although ptosis is usually an isolated problem, some children born with the condition may also have:
  • Eye movement abnormalities
  • Muscular diseases
  • Lid tumours or other tumours
  • Neurological disorders
  • Refractive errors

Congenital ptosis generally does not improve with time.

Children presenting with droopy eyelid/s are usually diagnosed following a thorough examination that includes a medical history, a family history, a history of any drug or allergic reactions, and a physical examination.

Congenital ptosis is often caused by poor development of the muscle that lifts the upper eyelid, known as the levator muscle. This muscle has more fatty or fibrous tissue than normal, and as a result it is weak.

Mild congenital ptosis can be monitored every 3-12 months, depending on the severity of the condition. Photographs are often helpful in this regard. Patients should be carefully examined for any changes in chin posture due to worsening of the ptosis. In severe cases, where there is an extreme chin-up head posture (ocular torticollis), early surgical intervention is required. Infants and toddlers with severe ocular torticollis may experience delays in mobility due to balance problems.

Although not all patients with ptosis require surgical intervention, children should be carefully monitored for any signs of amblyopia (poor vision due to the lack or loss of development of central vision during early childhood) or strabismus (crossed eyes). This is critical because a child's visual system develops and matures during the first 6 years of life.

Visual development is particularly fragile in the first few months of life. If the child's eyelid partially or fully covers their visual axis (amblyopia), their visual development will be affected because their eyelid is drooping severely enough to block their vision. Timely and appropriate treatments are essential to correct and preserve the child's vision.

If the amblyopia is recognized early, it may be corrected with eye patching, glasses or eye drops. Surgical intervention (occlusion therapy) may be necessary. The longer amblyopia is left, the harder it becomes to correct. Beyond 6 years the visual system is locked in and amblyopia cannot be reversed. Similarly, ptosis can also hide a "misalignment or crossing of the eyes". If this misalignment is not treated in early childhood (below the age of 6), permanent visual problems may result.

In addition, patients should be checked for astigmatism due to the compression of the droopy eyelid. Several children with ptosis experience astigmatism on the same side. Astigmatism occurs when ptosis changes the optics of the eye, resulting in a constant blurring of the visual image. If this is uncorrected, the resultant blurred image can also lead to amblyopia. Amblyopia that is not treated in early childhood persists throughout life and may lead to permanent vision loss.

Children with congenital ptosis may face psychosocial difficulties due to the abnormal position of their eyelid. Although the primary reason for repair is functional, surgery offers the opportunity for cosmetic improvements, by producing symmetry in lid, height, contour and eyelid crease. If surgery is not urgent, it may be delayed until age 3-4 years of age. This allows for more accurate pre-operative measurements.

When determining whether or not surgery is necessary and what procedure is the most appropriate, an ophthalmologist will take the following into account: the child's age, whether one or both eyelids are involved, the eyelid height, the eyelids lifting and closing muscle strength, and the eye's movements.

During surgery the eyelid lifting muscle (levator muscle) is tightened. In severe cases, where the levator muscle is extremely weak, the lid can be attached or suspended from under the eyebrow muscles. This allows the forehead to do the lifting.

Surgical repair of congenital ptosis generally produces excellent functional and cosmetic results. Bleeding and infection are possible but rare. In some cases, over or under correction of the lid height may occur. This can easily be adjusted by means of a suture, 1-2 weeks post-operatively. It is common for patients to have an inability to fully close their eye after ptosis surgery. This is temporary (the eyelids do not remain "stuck open") and resolves after a few weeks. It is important to use ointment or drops to keep the cornea moist. 50% of patients who undergo surgical repair may require further surgical intervention, 8-10 years after the initial surgery.

Most vision loss from amblyopia is preventable or reversible with the correct treatment. The recovery of vision depends on the maturity of the visual connections, the length of the visual deprivation, and the age at which therapy is resumed.

In general, ptosis needs to be corrected or treated for physical, functional and psychological reasons. The only type of ptosis that may improve with time is ptosis as a result of birth canal trauma or forceps. In these cases, the eyelid may be bruised or swollen.

Whether children undergo surgery for their ptosis or not, it is essential that they are examined regularly by an ophthalmologist for amblyopia, refractive disorders (need for glasses) and associated conditions. Even after surgery, focusing problems can develop as the eyes grow and change.

When to contact your doctor:
Patients with congenital ptosis may have other conditions that need to be appropriately addressed, such as amblyopia, strabismus, craniofacial abnormalities, and other neurological findings.

Any ptosis that develops over a period of days or weeks may be indicative of a more serious medical problem that requires further neurological and physical evaluation.

Jordan DR. Ptosis In Children. Insight: A Quarterly Report For Health Care Professionals Delivering Eye Care. 2001;6(4):1-4. Accessed March 21, 2013.

Knott A. Ptosis and Lid Lag. Updated February 18, 2011. Accessed March 23, 2013.

Penn Eye Care Scheie Eye institute. Ptosis. Penn medicine. Accessed March 23, 2013.

Suh DW. Congenital Ptosis Folow-up. Medscape Reference: Drugs, Diseases & Procedures. Updated March 9, 2012. Accessed March 20, 2013.

The Eye M.D. Association. Ptosis in Children and Adults: A Closer Look. The American Academy of Ophthalmology. Reviewed March 2011. Accessed March 23, 2013.