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Abstract: Congenital ptosis is a condition in which there is inadequate function of the levator muscle of the upper eyelid due to multiple factors such as genetics and development, resulting in insufficient unilateral upper eyelid opening height and eyelid obscuring the cornea. A five-year-old boy with a particular gaze posture due to a drooping eyelid was encountered in the outpatient clinic. If left untreated, the child’s visual development may be affected, and after admission, the ptosis on the affected side was surgically corrected, and the child’s upper lid masking was significantly improved after surgery.
Basic information】Male, 5 years old
Type of disease】Congenital ptosis
Hospital】China Academy of Medical Sciences Plastic Surgery Hospital
Date of Consultation】November 2021
Treatment plan】Surgical treatment (frontal flap suspension)
Treatment Period】3 days of inpatient treatment, postoperative follow-up
Results】Significant improvement in upper lid masking and successful discharge from the hospital
I. Initial consultation
The child is a 5-year-old boy with difficulty opening his right upper lid after birth, but it gradually opened a little with development. The child’s family complained of daily head tilting, head tilting, increased frontal lines, and asymmetric appearance of the upper lids bilaterally. On examination, there were no obvious signs of trauma or surgery around the eyes bilaterally, and bilateral visual acuity was fair. The child was seen in a tilted head position with increased frontal lines on the right (affected) side, upper lid covering 1/2 of the cornea, and increased eyebrow-to-cornea spacing. The upper lid motility was 3-4 mm on the right side and 7-8 mm on the left side, with significant upward movement of the eyeballs bilaterally when the eyes were closed (positive Bell’s sign). There were no abnormal findings on other basic physical examinations. The patient’s family complained of a similar case within a maternal relative, the details of which were not known. The diagnosis was severe congenital ptosis on the right side and severe congenital ptosis on the left side. The child was recommended for surgical treatment.
II. Treatment history
We explained in detail to the family that both sides had ptosis and that the degree of ptosis was uneven on both sides, but that the best option at this time was to correct the more severe ptosis on one side first and adjust the other side later, depending on the situation, which the family understood. Prior to surgery, the child’s eye opening height was marked on the bridge of the nose, and a transverse incision was made at a height of 3 mm from the eyelid margin, followed by separation along the deep surface of the orbicularis oris muscle toward the eyebrow to the orbital rim, taking care to avoid the supraorbital neurovascular bundle superficial to the supraorbital foramen. The free prepared frontalis flap is then sutured to the lid in the appropriate position. When the child was awakened from anesthesia, the child’s eye opening was examined and found to be close to the expected result, with similar corneal exposure on both sides and slight elevation on the side that had undergone surgery.
III. Treatment results
After surgery, the child’s recovery was rapid, with significant improvement in appearance and eye opening. The upper eyelid mobility improved to 6 mm, the gap in corneal exposure between the two sides became smaller and was basically the same, and the head lifting and deviated vision disappeared. Although the preoperative concern of increased left-sided ptosis was present as expected, the corneal exposure on both sides was approximately equal (MRD1 gap less than 1 mm) and neither side obscured the visual field, so it is likely that the child did not require further surgery and was discharged after 3 days of hospitalization.
IV. Precautions
While it is gratifying to see the improvement of ptosis, it is important to advise the child’s family to monitor the child’s corneal exposure during sleep after discharge; if there is too much exposure, there is a risk of dry corneal ulceration and a small amount of erythromycin eye ointment should be applied after sleep. At the same time, it is necessary to review the vision at the ophthalmology department and pay attention to the changes of the child’s posture when looking at things, avoiding the formation of habits of looking at things by tilting or tilting the head for a long time.
V. Personal insight
In this case, the patient was born with congenital ptosis and had a family history of the condition, so the parents came to the doctor quickly when they noticed the abnormality and were able to achieve a satisfactory result with surgical treatment. In addition, it is important to note that surgical treatment of this type of child should be done very carefully, and the surgeon needs to be aware that any operation may affect future development and should take a conservative and prudent approach whenever possible. However, in the face of difficulty, it is also necessary to challenge the difficulty without hesitation in order to achieve the greatest improvement. In combination, this is what is often referred to as “being bold and careful”.