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Abstract: If a child is born with small eyes, cannot open them, and has eyelids that rise as they grow and look down, most have congenital ptosis, which can affect physical and psychological development and lead to a morbid face. In this case, the child was diagnosed with congenital ptosis and underwent surgery in a timely manner, which resolved the problem of small eye fissures and improved the appearance of the upper and middle face with excellent results.
Basic information】Female, 6 years old
Type of disease】Congenital ptosis
Hospital】Air Force Military Medical University Xijing Hospital
Date of Consultation】April 2022
Treatment Plan] Single-incision direct suspension with an extra-wide frontal muscle flap
Treatment Period】7 days of inpatient treatment and 3 months of outpatient follow up
Results】The upper eyelid ptosis was corrected and the upper facial appearance was improved.
I. Initial Consultation
A 6-year-old child came to our hospital. The parents reported that the child had difficulty opening both eyes at birth, but due to the young age of the child, no special treatment was given. In order to open his eyes, the child raised his eyebrows vigorously, resulting in a special face, and at the same time, he also had some problems closing his eyes during sleep. On outpatient examination, the child was found to have a severe congenital ptosis with the upper lid covering the pupil >6 mm when both eyes were looking straight ahead. If left untreated, this may lead to abnormal development of the cervical spine due to prolonged head tilting, and may also lead to abnormal visual development.
Treatment history
The main reason the parents came to us was to address both their child’s cosmetic and functional problems. In this case of severe ptosis, because of the relatively high risk of bilateral surgery, it would be best to perform surgery on one side first and then the other side after recovery for safety reasons. However, after talking to the parents, they prefer to have bilateral surgery.
Because of the risks associated with ptosis surgery, especially in the early postoperative period when the eyelid may not close, it is important to prepare for the surgery. The child’s parents are asked to prepare a wet room lens in advance and to assist with eye closure tape, followed by an ophthalmologic examination to rule out corneal disease and prepare eye drops.
There are many surgical methods for ptosis, but because this child was not fully developed, a surgical method with less damage to the periocular structures was chosen, namely direct suspension with a single incision under an extra-wide frontalis muscle flap. During the procedure, a double eyelid incision was first designed for the child, and the frontalis muscle flap was peeled from the double eyelid incision and then used for lid suspension to make the eye larger. The results of this procedure are stable and less likely to recur after surgery, but it is difficult to close the eyes in the early postoperative period, and without delicate care, it may lead to keratitis, corneal ulcers, and in severe cases, loss of vision.
III. Treatment effect
At 7 days after surgery, the child was observed to be free of wound infection, and the child’s mental state and wound recovery were good, so he or she was discharged from the hospital for recuperation, and parents were asked to review at 1, 3 and 6 months after surgery. At 1 month after surgery, it was obvious that the child’s eyes were larger than normal, but the child’s eyebrows had been significantly lowered at this time. At about 3 months after surgery, the child basically returns to a more natural state, and both eyes can basically reach the level of normal people. Outpatient review shows that both upper lids are located at the upper edge of the cornea, and the treatment effect is satisfactory.
IV. Notes
We are glad that after active and effective treatment and care by the child’s parents, the child’s postoperative recovery of both eyes was more successful and the previously feared risks did not occur, but due to the long postoperative recovery period, parents should still not take it lightly after discharge from the hospital and usually need to pay attention to the following points.
1. Since a traction cord is usually placed on the lower lid after surgery, it is necessary to force the eyes closed at bedtime every day during this period. However, after 7 days of postoperative discharge, the traction cord is usually removed, but parents are still required to close the child’s eyes with tape every night to avoid corneal dryness, and to use saline to flush the eyes if necessary.
2. If the child needs to go out after surgery, he or she can wear wet room lenses to keep the cornea moist and prevent keratitis to the maximum extent possible.
3.The child should pay attention to rotate the eye more in daily life to keep the cornea moist.
V. Personal insight
Congenital ptosis is a common disorder in children and can occur in one eye or in both eyes. If it is detected at birth, parents do not need to worry too much and most children can be treated surgically when they are 3-4 years old or older. With timely treatment, most children will not develop abnormalities. However, there are some risks associated with ptosis surgery, and some children may have permanent corneal damage and subsequent visual acuity due to poor postoperative cooperation and lack of attention from the surgeon, as well as untreated corneal edema and inflammation after surgery.
In this case, the child recovered well from the surgery without the careful care of the parents. This child’s surgical treatment not only solved the problem of ptosis, but also improved the entire mid-upper face, which will have a great positive impact on the child’s psychological development and later life, and is very gratifying for the doctor.