Ptosis

Original Articles

Congenital ptosis: results of surgical management
Geoff M Whitehouse, FRACO John RB Grigg, FRACO, FRACS Frank J Martin, FRACO, FRACS

Abstract

Purpose: To determine the visual and cosmetic outcome following the surgical correction of isolated congenital ptosis. Methods: A retrospective review of the outcome of isolated congenital ptosis corrected under the supervisionof one surgeon at The Children's Hospital, Camperdown, between January 1983 and January 1993 was examined. Some 65 patients with 80 involved eyes were identified; 30 eyes underwent a levator resection procedure, 40 eyes underwent a brow suspension using donor stored fascia lata, and in 10 eyes a brow suspension was performed using mersilene mesh. Results: In 7 8 eyes of 63 patients, a good cosmeticresult was achieved. In two patients (two eyes) a poor cosmetic result was achieved. These two patients refused further surgery following an undercorrection of their initial ptosis. The recurrence rates for the primary procedures were 16.7% for levator resection procedures, 35% for brow suspension procedures using donor fascia lata, and 30% for brow suspension surgery using mersilene mesh. Some35.3% of eyes following mersilene slings required further surgery for granulomas and exposed mersilene mesh compared with 6% having similar complications with stored fascia lata. Nine patients (11.25%) had reduced visual acuity (one line or more on the Snellen chart or its equivalent with the other tests used) on the operated side. Only one patient was found to have significant astigmatism.Conclusions: An acceptable cosmetic result was achieved with one operation in 75.3% of cases. In 20.8% of cases a second operation was required and in 3.9% of cases three or more operations were required. This series supports the view that where possible, levator resection is the preferred form of surgery to correct congenital ptosis. When the levator function is inadequate, brow suspension isperformed. The use of donor fascia lata resulted in a good cosmetic appearance with a low occurrence of surgical side effects. Amblyopia, when strictly defined, occurred in 11.25% of eyes despite early surgery for severe cases and intensive amblyopia therapy. Management requires repeated follow up for early detection and introduction of occlusion therapy or surgical ptosis correction. Key words:Amblyopia, congenital ptosis, surgical complications, surgical outcome.
Congenital ptosis is a relatively uncommon condition. It accounts for approximately one per cent of all ophthalmic surgery performed at The Children's Hospital, Camperdown, Sydney. Though most cases occur in isolation, 10% are associated with a syndrome such as MarcusGunn jaw winking or blepharophimosis. Congenital ptosis is due toa dysgenesis of the levator complex, with the muscle fibres being replaced by fibrous and areolar tissue.' There is correlation between the degree of ptosis, and hence levator function, and the amount of abnormal tissue. This leads to the classical clinical picture of ptosis in the primary position

From The Children's Hospital, Sydney, Australia. Reprints: Dr FJ Martin, Head, Department ofOphthalmology, The Children's Hospital, Camperdown 2050, New South Wales.
Congenital ptosis: results of surgical management

309

and in upgaze, lagophthalmos in downgaze, decreased levator function, poor eyelid crease and poor eyelash position.2 Surgical correction is required if the ptosis occludes the visual axis causing amblyopia, if there is an abnormal head posture or for cosmetic reasons.Simple unilateral congenital ptosis rarely occludes the pupil to produce amblyopia.

Method A retrospective analysis was made of all cases of surgically corrected isolated congenital ptosis performed by or under the supervision of one surgeon (FM), at The Children's Hospital Sydney, Australia from January 1983 to January 1993. Cases which were associated with other systemic or ocular problems...