Congenital Ptosis in Infants: Treatment Options and Timing

Congenital right eyelid ptosis in infants?

Dear Dr.
Liu,
I have a granddaughter who has congenital ptosis in her right eye.
She was not a premature baby, and during her first month, she could only open her eye a little bit.
Now, at over four months old, she can open it to about half of what her left eye can do.
All other aspects of her development are normal; she was able to roll over by herself at three months.
I am very concerned about her future vision and the potential for self-esteem issues.

We have taken her to see an ophthalmologist, but one doctor said surgery could only be performed at age three, while another said it could be done at one year.
I also found information online suggesting that surgery could be considered as early as six months.
This has left me feeling uncertain.

I would like to ask you, Dr.
Liu:
1.
Is surgery absolutely necessary in this situation? Are there any other options to consider besides surgery?
2.
If surgery is required, what would be the optimal timing for it?
Thank you! I hope you can provide me with some advice.
Sincerely,
A concerned grandmother

Xinji da ma, 40~49 year old female. Ask Date: 2005/06/27

Dr. Liu Jingxian reply Ophthalmology

Dear Concerned Grandma,
Congenital ptosis is caused by the underdevelopment of the levator muscle of the eyelid.
Symptoms of this eye condition include: drooping of the upper eyelid, difficulty opening the eyes; tilting the head back with the chin elevated; and raising the brow when attempting to open the eyes forcefully, among others.
The treatment principles depend on the severity of the ptosis:
1.
If an infant is born with moderate to severe ptosis, especially if it is unilateral, surgical intervention should be performed before the age of one to prevent amblyopia.
(The mechanism of "amblyopia": During the process of visual development, the eyes and visual centers need to receive adequate light and visual stimuli to develop properly.
If ptosis occurs during this developmental period (before the age of six), it can obstruct light from entering the eye and focusing on the retina, potentially leading to amblyopia.)
2.
If the ptosis is not very severe, the appropriate time for surgery is between three to five years of age, which can help prevent feelings of inferiority when the child starts elementary school.
3.
Assessing the severity of ptosis in infants is challenging compared to adults.
Therefore, if the lower margin of the upper eyelid does not cover the pupil when the eye is open, it indicates that the ptosis is not severe.
In such cases, surgery can be postponed until the child is older and the eyelid tissue is more developed.
Conversely, if the eyelid does cover the pupil, surgery should be performed before the age of one to avoid future amblyopia in the affected eye.
Wishing you good health.
Dr.
Liu Ching-Hsi, Ophthalmology
Taipei City Hospital, Zhongxing Branch, Taiwan e-Learning Academy

Reply Date: 2005/06/27

More Info

Congenital ptosis, or eyelid drooping, is a condition that can significantly impact an infant's vision and self-esteem as they grow. In your granddaughter's case, it is understandable that you are concerned about her visual development and the potential for self-consciousness as she matures. Let's address your questions regarding treatment options and timing.

1. Is Surgery Necessary for Congenital Ptosis?
Surgery is often the most effective treatment for congenital ptosis, especially if the drooping eyelid is severe enough to obstruct vision. The primary goal of surgical intervention is to elevate the eyelid to a position that allows for proper visual function and to improve the cosmetic appearance. However, not all cases require immediate surgical correction.
In some instances, if the ptosis is mild and does not significantly obstruct vision, doctors may recommend a watchful waiting approach. This is particularly true if the child is developing normally in other aspects and if the ptosis does not interfere with visual development. Regular follow-ups with an ophthalmologist are essential to monitor the condition and ensure that the child’s vision is not being compromised.

2. What Are the Alternatives to Surgery?
While surgery is the most definitive treatment, there are non-surgical options that may be considered, particularly in very young infants. These can include:
- Observation: In cases where the ptosis is mild and not affecting vision, doctors may recommend simply monitoring the condition as the child grows.

- Ptosis Crutch: This is a temporary device that can be attached to glasses to help hold the eyelid up. This option is generally used for older children or adults but can be discussed with an ophthalmologist for infants if surgery is not immediately indicated.

3. When is the Optimal Time for Surgery?
The timing of surgery for congenital ptosis can vary based on the severity of the condition and the specific recommendations of the ophthalmologist. Generally, surgery is considered when:
- The child is at least 3 years old, as this is when they can better cooperate during the procedure and postoperative care.

- However, if the ptosis is significantly affecting vision or if there are concerns about amblyopia (lazy eye), surgery may be performed earlier, sometimes as early as 6 months to 1 year of age.

In your granddaughter's case, since she is currently 4 months old and showing some improvement in her ability to open her eye, it may be beneficial to continue monitoring her progress. Consulting with a pediatric ophthalmologist who specializes in ptosis can provide you with tailored advice based on her specific situation.

Conclusion
In summary, while surgery is often the recommended treatment for congenital ptosis, the decision should be made based on the severity of the condition and its impact on vision. Non-surgical options exist but may not be suitable for all cases. The timing of surgery can vary, with many specialists recommending waiting until the child is older unless vision is at risk. Regular follow-ups with an ophthalmologist will be crucial in determining the best course of action for your granddaughter. Your concerns as a grandmother are valid, and seeking the best care for her is essential for her development and well-being.

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