A 16-year-old boy presented with triple-A syndrome associated with neuromuscular disorders: a case report

Introduction and importance

Allgrove syndrome (AS) (AAA syndrome) is a rare autosomal recessive disease caused by mutations in the AAAS gene located on chromosome 12q13. The AAAS gene encodes for the ALADIN protein (alacrima, achalasia, adrenal insufficiency, neurologic disorder). AS can manifest with a plethora of symptoms. Early recognition of the syndrome remains challenging due to its rarity and progressive nature. This report presents an unusual case of triple-A syndrome (TAS) with concurrent neuromuscular manifestations. Understanding the atypical presentation of this syndrome is vital for early diagnosis and appropriate management.

Case presentation

We report a 16-year-old boy with severe malnutrition presented with painful swallowing, fatigue, and bilateral congenital ptosis. Barium swallow, upper gastrointestinal endoscopy, and Shimmer test were performed, which led to the diagnosis of TAS. Treatment included laparoscopic Heller's procedure, artificial tears, hydrocortisone.

Clinical discussion

TAS, also known as AS, is a rare multisystem disorder characterized by achalasia, Addison's disease, and alacrima. This syndrome is occasionally referred to as 4A syndrome due to the inclusion of autonomic dysfunction. There is no treatment for AS. Management includes artificial tears for alacrima, glucocorticoid replacement therapy to treat adrenal insufficiency, and treatment of achalasia.

Conclusion

This case emphasizes the importance of considering atypical presentations of TAS. Early diagnosis and treatment are paramount in addressing the varied components of this rare disorder. Understanding the clinical complexities of this syndrome aids in improved patient care and underscores the necessity for comprehensive evaluation and management in similar cases.

Surgical Outcomes After Frontalis Suspension Using Expanded Polytetrafluoroethylene Sling for Congenital Ptosis

Purpose The purpose of the study is to assess short- and long-term functional outcomes after frontalis suspension using expanded polytetrafluoroethylene (ePTFE) sling for congenital ptosis repair. Methods A retrospective, observational case review was conducted on pediatric patients who underwent frontalis suspension using ePTFE sling from 2008 to 2020. Functional success was assessed by lid height, lid symmetry, and parental satisfaction with the cosmetic outcome. Clinical course and long-term functional outcomes after surgery were assessed. Results Twenty-one cases met the inclusion criteria and were assessed. The follow-up time ranged from 13 months to 11 years (mean: six years). Functional success after one surgery was 62% at early and late postoperative periods. Six of 21 cases (29%) required revisional surgery in the early postoperative period due to undercorrection. Three cases (14%) were complicated by infection and/or granuloma formation. There were no cases of ptosis recurrence in the long term if success was seen in the early postoperative period. Conclusion ePTFE slings remain an excellent option for severe congenital ptosis repair with frontalis sling, demonstrating long-term functional success, with satisfactory lid symmetry and acceptable cosmetic outcome. This is of important consideration in patients younger than three years of age, where autogenous materials may not be recommended. The need for early revisional surgery for undercorrection is not uncommon. The current authors also demonstrate a low but considerable risk for infection and/or granuloma formation.

Congenital Ptosis Associated With Adduction as a Dysinnervation Disorder: A Report of a Rare Case

The levator palpebrae superioris is the primary muscle responsible for elevation of the eyelid. This muscle is innervated by the third intracranial nerve. Any pathology affecting the muscle or the supplying nerve can lead to blepharoptosis. In this study, we share our experience of a two-year-old baby boy patient who presented with a rare congenital disorder manifested as blepharoptosis increased with adduction bilaterally with no limitation of ocular muscles action except bilateral underaction of inferior oblique muscles. To our knowledge, this unusual presentation has not been previously reported in the literature. We aim in this report to build more knowledge on such a rare clinical presentation. Based on the findings, this could be a case of congenital innervation dysgenesis syndrome (CID)/congenital cranial dysinnervation disorders (CCDDs). CCDDs/CID is a group of conditions that includes blepharoptosis as part of their clinical presentation. This group of conditions includes Duane's retraction syndrome, congenital fibrosis of extraocular muscles, and monocular elevation defect.

Silicone sling frontalis suspension for congenital ptosis: Outcome of 174 consecutive cases

BACKGROUND

Frontalis suspension (FS) is the treatment of choice in congenital ptosis with poor levator function. We report the surgical outcome of FS using a double triangle configuration of silicone slings in children.

METHODS

A retrospective cohort study of all paediatric patients with simple myogenic congenital ptosis repaired with FS over a 12-year period (2009-2020). Each silicone sling was secured by simple knots. Pre- and post-operative margin reflex distance (MRD₁ ) measurements were determined from clinical photographs using ImageJ Software. Main outcome measures were improvement in eyelid height, eyelid asymmetry, reoperation rate and timing.

RESULTS

One hundred and thirty nine patients (174 eyes) were included, with 35 (25%) having bilateral surgery. Mean (±SD) age was 1.4 ± 1.9 years. Mean follow up time was 32 ± 20.5 months. Sixteen patients (11%) had a history of previous ptosis repair surgery. Mean MRD₁ improved by an average of 1.5 mm. The final MRD₁ in the group of patients who did not have a second procedure was a mean of 2.1 mm. The MRD₁ difference between both eyes in all unilateral cases improved from 2.5 mm preoperatively to 1.2 mm at final visit (p < 0.001). In the 123 cases without a history of previous ptosis surgery, repeat ptosis repair was performed in 37 (30%) patients, 34.9 ± 19.9 months after the initial procedure. Overall, repeat repair was performed in 47 patients (34%).

CONCLUSIONS

Double triangle silicone sling frontalis suspension has a favourable outcome in two-thirds of paediatric patients with simple myogenic congenital ptosis. Failed cases can be addressed with a second repair, using either autogenous fascia lata or a second silicone sling.

Minimally invasive harvesting fascia lata (FL) in ophthalmic plastic surgery

PURPOSE

To describe a minimally invasive technique of harvesting fascia lata, and also to analyze the clinical uses and the outcome of fascia lata in Ophthalmic Plastic and Reconstructive surgery.

METHODS

This interventional study was done in three tertiary care eye hospitals in Bangladesh from July 2014 to June 2020. We obtained autologous fascia lata for the correction of congenital ptosis with poor levator function (⩽4 mm), covering the ciliary staphyloma, repair of the extruded implant following anophthalmic socket surgery, and was also used to wrap the orbital implant after enucleation. Preserved FL was used only for children before 6 years of age for the treatment of congenital ptosis.

RESULTS

Out of 60 subjects, 38 (63.3%) were male and 22 (36.7%) were female. Autogenous fascia lata was used for frontalis brow suspension (FBS) in 25 (41.67%) patients of congenital ptosis with poor levator function, as patch graft in ciliary staphyloma (11 cases, 18.3%), to wrap orbital implant following enucleation in intraocular malignancies (nine cases, 15%), to repair of implant extrusion following evisceration (five cases, 8.3%), and as fascial sling to correct recurrent paralytic ectropion (one case, 1.67%). Allogeneic or preserved fascia lata was used to correct congenital ptosis in patients less than 6 years of age (nine cases, 15%). Mean follow-up time was 5.32 months.

CONCLUSION

Fascia lata (autogenous and allogeneic preserved) has varied uses in ophthalmic plastic surgery. Harvesting fascia lata (FL) using with minimally invasive method was successful with the least scar on the thigh to correct congenital ptosis, ciliary staphyloma, repair of extruded implant, and in wrapping implant after enucleation to get better cosmesis and motility.

Effect of congenital ptosis correction on corneal topography- A prospective study

Purpose:

The aim of this study was to evaluate the changes in corneal topography, cycloplegic refraction, and best-corrected visual acuity (BCVA) after ptosis correction surgery in patients with congenital ptosis.

Methods:

Our study represents a prospective observational study conducted on 27 eyes of 21 patients with congenital ptosis. All patients underwent complete ophthalmological evaluation, cycloplegic refraction, and baseline Orbscan prior to ptosis surgery. At 6 months postoperative review, the cycloplegic refraction and Orbscan were repeated to evaluate the changes in these parameters. The main outcome measures in our study were Steepest K, Inferior-Superior Asymmetry (I-S Asymmetry), cycloplegic refraction and BCVA.

Results:

A significant decrease in Steepest K postoperatively (P < 0.001) was noted. Superior K and Inferior K also decreased, but the decrease in Inferior K was statistically significant (P = 0.044). However, change in I-S Asymmetry was not significant. Variation in BCVA, and cycloplegic sphere and cylinder was minimal. Sim K astigmatism, Surface Regularity Index, I-S Asymmetry and Central Corneal Thickness did not show significant variation.

Conclusion:

Ptotic eyelid constantly presses on the cornea causing significant changes in corneal contour and surface remodeling. This pressure when relieved, results in significant flattening and regression of anterior corneal surface to its near normal anatomy. This further resulted in improvement of corneal surface irregularity and symmetry.

A Family With Novel X-Linked Recessive Homozygous Mutation in ANOS1 (c.628_629 del, p.1210fs∗) in Kallmann Syndrome Associated Unilateral Ptosis: Case Report and Literature Review

OBJECTIVE

Kallmann syndrome (KS) may be accompanied by anosmia or hyposmia and midline defects. We present an overweight 16-year-old boy with a lack of puberty, anosmia, congenital right eye ptosis, and normal intellectual function.

METHODS

Testicular ultrasonography was performed. Whole-exome sequencing was performed on peripheral blood specimens. Genetic results were confirmed by Sanger sequencing. Anosmia was evaluated quantitatively using the Korean version of the Sniffin' stick test II.

RESULTS

Our patient presented with a complaint of lack of body hair growth and small penile size with no remarkable medical history. He was the second son of third-degree consanguineous healthy parents. Physical examination revealed pubertal Tanner stage I. Congenital right eye ptosis and obesity were noted. Anosmia was confirmed. The laboratory evaluation revealed a low serum level of testosterone, follicle-stimulating hormone, and luteinizing hormone. An X-linked recessive homozygous mutation, c.628_629 del (p.1210fs∗) in exon 5 of the ANOS1 gene was revealed and was also found in the patient's uncle and great uncle on the mother's side.

CONCLUSION

To date, approximately 28 ANOS1 mutations producing KS phenotypes have been described. However, to the best of our knowledge, this particular X-linked recessive mutation has not been previously reported in KS. Furthermore, ptosis is a rare finding in KS literature. Identification of these cases increases awareness of the phenotypic heterogeneity in novel forms of KS, thereby expediting early definitive treatment, which may prevent the development of further complications.

Eyebrow Elevation as a Prognostic Factor for Success of Frontalis Suspension in Severe Congenital Ptosis

Purpose

The study aims at evaluating eyebrow elevation as a prognostic factor for frontalis sling procedure success in patients suffering from severe congenital ptosis with poor levator function.

Patients and Methods

This is a retrospective study that included 66 eyelids of 57 patients selected from a surgical log database between January 2016 and June 2019. All of them underwent frontalis suspension surgery for treating severe congenital myogenic ptosis with poor levator function. Based on the absence or presence of brow elevation, patients were divided into two groups: 1 and 2, respectively. The latter was further subdivided into subgroup A with unilateral brow elevation and subgroup B with bilateral brow elevation. All included cases completed 6 months of follow-up after surgery. Postoperative functional outcomes in the form of margin reflex distance (MRD1) and palpebral aperture (PA) were recorded and correlated to preoperative brow elevation status.

Results

Both principal groups showed improvement of MRD1 and PA compared to the preoperative values. There was no statistically significant difference between both groups for the tested parameters in the 1st postoperative week. By the 6th postoperative month, MRD1 and PA showed statistically significant higher values in group 2 compared to group 1 (p<0.001). However, the difference between subgroups A and B was statistically insignificant for the same parameters.

Conclusion

Eyebrow elevation is significantly associated with the success of frontalis suspension procedure. Hence, brow position evaluation should be included in the preoperative assessment of patients undergoing frontalis suspension for congenital ptosis.

Histological findings of levator muscle in unilateral congenital ptosis in different age groups

PURPOSE

To evaluate the different degree of muscle atrophy in specimens of levator muscle of patients operated on for unilateral congenital ptosis, as related to the age of the patient.

METHODS

Histological analysis of the specimen of the levator muscle of 29 patients who underwent a unilateral levator muscle resection under the care of one surgeon was performed. The study population was divided into two different groups according to the timing of surgery: group 1 included 15 children operated on at 2 to 4 years, and group 2 included 14 children operated on at 4.1 to 11 years.

RESULTS

Levator muscle of 12 patients of group 1 showed mild degree of muscle atrophy, with striated muscle fibres separated by thin fibrous septa incorporating groups of cells with peripheral nuclei and non-hyalinized cytoplasm (Masson's trichrome stain). In eight cases of group 2, levator muscle showed instead severe atrophy, with discontinuous striated muscle fibres separated by thick fibrous septa including cells with centralization of nuclei, hyalinization of cytoplasm (Masson's trichrome stain) and fatty infiltration.

CONCLUSION

Myofibres found in specimens of levator muscle following levator resection for congenital ptosis show characteristics of a degenerative process. This study seems to demonstrate that atrophy in the levator muscle appears to be related to the age of the patient at surgery, as atrophy tends to be more evident in older children with congenital ptosis.

Prevalence of amblyopia in congenital blepharoptosis: a systematic review and Meta-analysis

AIM

To conduct a systematic review and Meta-analysis of the published literature to evaluate the pooled prevalence rate of amblyopia in patients with congenital ptosis.

METHODS

We searched the PubMed, Embase, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Wanfang Data, and Chongqing VIP databases for studies reporting the prevalence of amblyopia in patients with congenital ptosis. The reference lists of relevant studies were scanned. Heterogeneity of effect sizes across studies was tested. We calculated prevalence ratios to compare prevalence estimates for different causes of amblyopia in patients with congenital ptosis, as well as for different geographical regions, year of publication and sample size in subgroup analyses. A systematic review and Meta-analysis were performed.

RESULTS

We identified 29 eligible surveys with a total population of 2436. Prevalence rates of amblyopia ranged from 13.8% to 69%. We noted substantial heterogeneity in prevalence estimates for amblyopia in congenital ptosis (Cochran's χ ² significant at P<0.0001; I ²=90%). The pooled prevalence using random-effects models of 29 studies was 32.8% (95%CI: 27.3%-38.4%) in the overall population. Compared to the overall pooled prevalence, amblyopia prevalence was higher in studies in which only subjects with blepharophimosis syndrome were included.

CONCLUSION

We confirm that nearly one-third of congenital ptosis patients are suffering from or at risk for amblyopia. Patients with blepharophimosis syndrome are more likely to develop amblyopia. The identification and management of amblyopia should be integral to the treatment of congenital ptosis.

How far we have come: A review of the evolution of posterior approach ptosis surgery

We revisit the evolution of posterior approach ptosis surgery. We address the early attempts at ptosis surgery, assess the more modern approach by de Blaskovics, followed by the division into "open sky" and "closed" techniques. The simultaneous developments occurring in America and Europe are described, along with refinement of surgical approaches such as conjunctival-sparing posterior approach ptosis surgery.

Ultrasound biomicroscopy image patterns in normal upper eyelid and congenital ptosis in the Indian population

Purpose

To study the features of upper eyelid in healthy individual and different types of congenital ptosis in the Indian population using ultrasound biomicroscopy (UBM).

Methods

This was a prospective observational study at a tertiary care center. Eyelid structure of healthy individuals with no eyelid abnormalities (n = 19); simple congenital ptosis (n = 33) cases; Marcus Gunn jaw-winking ptosis (MGJWP, n = 7) cases, and blepharophimosis-ptosis-epicanthus inversus syndrome (BPES, n = 20) cases were studied on a vertical UBM scan using 50-MHz probe. Lid-thickness, tarsal-thickness, orbicularis oculi and levator-Muller-orbital septum-conjunctival (LMSC) complex were measured in primary gaze. Comparison was made between four groups and results were statistically analyzed using ANOVA test. In normal individuals, LMSC measurements were repeated in down-gaze imaging.

Results

Skin with subcutaneous tissue, LMSC complex and pre-aponeurotic fat-pad appeared echodense while orbicularis oculi and tarsus appeared echolucent. In primary gaze, mean thickness (± standard deviation) of the eyelid, tarsus, orbicularis oculi and LMSC, respectively, were: 1.612 ± 0.205, 0.907 ± 0.098, 0.336 ± 0.083, and 0.785 ± 0.135 mm in normal individual. LMSC showed 46.64% increase in thickness on down-gaze. The mean eyelid thickness and LMSC were thicker in MGJWP and BPES as compared to normal. In different types of congenital ptosis cases, various patterns of UBM imaging were observed.

Conclusion

UBM allows noninvasive imaging of eyelid structures with good anatomical correspondence in normal eyelids and study the structural alterations of eyelids in different types of congenital ptosis. UBM can be used to highlight the anatomical difference in normal eyelids that may help modify the surgery for better cosmetic outcomes. Furthermore, it has the potential to be used in preoperative evaluation and operative planning in certain types of acquired ptosis, which needs to be evaluated.

Timing of surgical correction for the treatment of unilateral congenital ptosis: Effects on cosmetic and functional results

The authors analyzed the cosmetic and functional results of a series of patients with unilateral congenital ptosis who underwent levator resection, to compare the outcome of surgery according to the age of intervention, and to evaluate the chance of ptosis recurrence in different age groups. Analysis of the clinical charts of 44 patients who underwent a unilateral levator muscle resection under the care of one surgeon from February 2000 to March 2012 was performed. Age at the time of surgery ranged from 2.1 to 12 years. The study population was divided into different groups according to the age of surgery. Preoperative evaluation included measurements of upper eyelid margin reflex distance (MRD1), levator function, frontalis function, and complete extraocular motility examination. This study adheres to the principles outlined in the Declaration of Helsinki. The patients' follow-up ranged between 2 and 12 years. The outcome of surgery was more satisfactory (MRD1 increase: p < 0.002) and the increase of levator function was better (p < 0.0001) when surgery was performed in children aged 2 to 4 years. No ptosis recurrence was observed in children aged 2 to 4 years, as opposed to 6 (22%) children of other groups (p = 0.067). Unilateral levator resection effectively reduces the asymmetry between eyelids. The age of the operation appears to influence the outcome of surgery, as in this series cosmetic and functional results are better and the rate of ptosis recurrence is lower if the child is operated on before the age of 4 years.

Early onset bilateral juvenile myasthenia gravis masquerading as simple congenital ptosis

Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junction. Ocular myasthenia gravis presents as ptosis with extraocular motility restriction and is prone to be misdiagnosed as third nerve palsy or congenital or aponeurotic ptosis. Juvenile ocular myasthenia gravis in very young children is difficult to diagnose and can be easily labeled as a case of congenital ptosis, the more so when the condition is bilateral. We present a case of a two-year-old child who presented with bilateral ptosis and was diagnosed as a case of simple congenital ptosis elsewhere with the advice to undergo tarsofrontalis sling surgery. The child was diagnosed with juvenile myasthenia gravis on thorough history, examination, and systemic evaluation and was started on anti-myasthenic treatment.

Cosmetic and functional outcomes of frontalis suspension surgery using autologous fascia lata or silicone rods in pediatric congenital ptosis

PURPOSE

Cosmetic and functional outcomes of frontalis suspension surgery using autologous fascia lata (FL) or silicone rods (SRs) in pediatric congenital ptosis.

DESIGN

Retrospective case series.

STUDY SUBJECTS

Patients with congenital ptosis, aged 18 years or younger, during the period under study (2005-2011) at the Singapore National Eye Centre.

METHODS

Review of case records for functional and cosmetic outcome measures after frontalis suspension surgery using either SRs or autologous FL.

RESULTS

A total of 18 patients were studied (14 eyelids had FL, 16 eyelids had SRs) with mean ages of 7.1 (range 5-12) and 7.2 (range 4-18) years for the FL and SR groups, respectively. Mean follow-up period was 41.6 (range 11.2-77.9) and 48.6 (16.1-87.4) months, respectively. Patients in the FL group had better functional and cosmetic results compared to those in silicone group, with no recurrence of ptosis. More complications were experienced by patients in the SR group.

CONCLUSION

Autologous FL for frontalis suspension remains an excellent choice for (and should be considered as useful surgical armamentarium for) repair of severe congenital ptosis.

Suspension surgery with autogenous fascia lata via a less invasive modification of the Crawford method on 85 patients with congenital severe eyelid ptosis

BACKGROUND

Autogenous fascia lata is considered the gold standard for frontalis suspension surgery to correct severe congenital upper eyelid ptosis.

METHODS

This study evaluated the efficacy of a less invasive modification of the standard technique described by Crawford. A total of 85 patients with severe congenital ptosis were enrolled in this study and submitted to surgical correction by frontalis suspension using autogenous fascia lata. Among these patients, 51 had previously undergone ptosis correction using other surgical techniques. The final lid level and contour were evaluated in addition to complications, such as lagophthalmos and ptosis recurrences.

RESULTS

Overall, the final results were evaluated as good in 71 of the cases, whereas 11 cases were graded as satisfactory and three cases as poor according to the success criteria. The average increase in eyelid height, measured as the marginal reflex distance (MRD), was 2.9 mm. The best results were obtained in the group of patients with no previous eyelid surgeries. The examples of poor results could be attributed to lagophthalmos and were all confined to the group of patients with a previously failed surgery that employed synthetic suspension materials and levator shortening procedures. No recurrences were observed during the follow-up interval, which lasted an average of 6.4 months (range = 2-59 months).

CONCLUSIONS

This technique allows a safe surgery with an overall high rate of success. This surgery is also safe and successful in cases of congenital ptosis with associated abnormalities, such as blepharophimosis, and in cases that require secondary ptosis repair.

Controversies and advances in the management of congenital ptosis

The management issues associated with pediatric ptosis begin with determining the etiology of the ptosis, and considering how the eyelid position affects the child's visual and psychosocial development. These ultimately determine if and when surgical management should be undertaken. Surgical challenges include the lack of intraoperative feedback regarding the dynamic eyelid height and contour under general anesthesia. When the eyelid elevators do not function or if there is little drive to lift the involved eyelid, obtaining good surgical outcomes can be extremely challenging. A plethora of surgical techniques and materials have been developed, each with their own benefits and drawbacks. Careful preoperative evaluation, planning and counseling can usually result in satisfactory surgical results with happy parents and patients. Families should always be aware that the child will need to be followed long term for visual development, ocular health, and they need to be counseled regarding the possibility of revision surgery.

Five-Year Follow-Up of a 30-Month Trial of Stability of Silicone Band Frontalis Suspension for the Treatment of Severe Unilateral Upper Eyelid Ptosis in Infants

PURPOSE

To evaluate the five-year stability of frontalis suspension of the upper eyelid with a silicone band for the treatment of severe congenital ptosis in infants.

METHODS

Chart review of pediatric patients with a follow-up of five years after unilateral frontalis suspension with silicone band was reviewed. Margin-reflex distance (MRD) and corneal staining were measured at different follow-up visits. Data were analyzed by analysis of variance and t test for paired data.

RESULTS

Twenty pediatric patients were included in this retrospective study. MRD was severely reduced before surgery in all cases: it ranged from -1 mm to -4 mm (-2.4 ± 0.8 mm). After surgery, MRD increased to 2.9 ± 0.3 mm, and then progressively decreased by 0.6 mm within the first three months (p < 0.001); a further reduction of 0.2 mm, occurring between three and 12 months after surgery, was not statistically significant (p < 0.001). Between the 12-month and the five-year follow-up visits (one visit every six months), no changes in MRD were found for any patient. After the five-years visit, no substantial changes were recorded in 18 patients (90%); in two patients, a second surgery to improve the deterioration was necessary. Corneal staining, which was present in five patients (25%) during the first two postoperative weeks, disappeared over five years of follow-up.

CONCLUSIONS

During the five-year follow-up of this retrospective study, the frontalis suspension with a silicone band proved to be a stable procedure. After 30 months from the first observation, MRD values were stable, except for two patients that underwent a second surgery to stabilize the worsening ptosis.

Frontal suspension for congenital ptosis using an expanded polytetrafluoroethylene (Gore-Tex(®)) sheet: one-year follow-up

Background

The frontalis suspension technique is the surgical method of choice in patients with ptosis and a levator function of 4 mm or less. Several types of materials have been used, including Gore-Tex^®, which has been used successfully as a frontalis sling material since 1986. Recently, a Gore-Tex sheet (wider than a sling or strip) suspension was reported. This paper reports the results of 27 eyes from 20 patients with congenital ptosis treated using the frontalis suspension technique with the newly developed Gore-Tex Most Versatile Patch (MVP) sheet.

Methods

All patients underwent surgery between April 2007 and September 2011 and were followed up for at least one year. The average follow-up duration was 18 months, with a range of 12–36 months. The average patient age was 45 (5–85) years, and the group included 11 males and nine females. Thirteen cases demonstrated ptosis in one eye, and seven cases involved both eyes. The patients were divided by age into a younger group and an older group. All ptosis procedures were performed using the Gore-Tex MVP sheet. The implant was normally 7 mm wide for adults and 5 mm wide for children. The implantation method was the same as that used for the sheet shape fascia.

Results

In all patients, satisfactory functional results were observed at the 6-month follow-up examination. Eyelid opening heights were also obtained. The average marginal reflex distance (MRD) was −0.5 mm preoperatively, which improved to +1.9 mm after surgery. After one year, average MRD was +1.6 mm. MRD attenuation was more frequent in the younger group. There were no cases requiring redo surgery and only one case of exposure.

Assessing amblyogenic factors in 100 patients with congenital ptosis

AIM

To study the frequency of amblyogenic factors in patients with congenital ptosis.

METHODS

In this cross-sectional study, 114 eyes of 100 patients with congenital ptosis more than 1 year old were included. Amblyopia was defined as best-corrected visual acuity (BCVA) less than 10/10 or a difference between the two eyes of at least 2/10. In patients too young to be measured by the linear Snellen E test, fixation behavior was observed. Different types of amblyopia were assessed for each patient as: 1) anisometropic amblyopia: astigmatic anisometropia ≥1 dpt, hyperopic spherical anisometropia ≥1 dpt, myopic spherical anisometropia ≥-3 dpt (with cycloplegia); 2) strabismic amblyopia, and 3) stimulus deprivation amblyopia (SDA). Then the total incidence of amblyopia and each type of it were obtained. Patients with uni- and bi-lateral ptosis were also compared.

RESULTS

The incidence of amblyopia in ptotic eyes was 39/114 (34.2 %), and for each specific cause was: refractive amblyopia in 29.8%, SDA in 10.5%, strabismic amblyopia in 4.3%. Amblyopia was more frequent in severe ptosis, 76% in patients with covered optical axes (OA), compared to non-covered OA (22.5%). In unilateral ptosis with covered OA, astigmatic anisometropic amblyopia was more frequent, and in bilateral ptosis with at least one eye covered OA, spherical anisometropic amblyopia was more frequent. In both unilateral and bilateral ptosis, SDA was more common if the OA was covered.

CONCLUSION

As refractive anisometropic amblyopia is more prevalent than SDA, paying attention to all causes of amblyopia may be important in preventing amblyopia in a child with a ptotic eye.