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Pediatric Ptosis

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Albert and Jakobiec's Principles and Practice of Ophthalmology

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Abstract

Pediatric ptosis is always a challenge to properly diagnose and treat. It is critical to address any impact on a child’s visual development, and timely interventions should be considered. As in adult ptosis, children may have myogenic, neurogenic, mechanical, and aponeurotic etiologies for ptosis. Early diagnosis and proper work up for associated systemic risk factors should be considered when encountering a pediatric patient with ptosis. While the incidence of ptosis is roughly 1:1000 live births, congenital ptosis may not be appreciated in the immediate postnatal period. Family photos and close follow-up are warranted for ptosis that encroach and cover the central visual axis with early intervention considered for the most severe cases. As in congenital cataracts, ptosis surgery can be considered for cases of severe visual deprivation when a child is 6 weeks of age or older.

In the work up for congenital ptosis, neuroimaging is rarely necessary with the exception of neurogenic etiologies. Adequate visual function testing is also very helpful in the early detection of visual delay. This includes the use of preferential gaze testing, such as Teller visual acuity cards, and less practically visual evoked potential testing. The timing of surgical intervention is controversial in cases of moderate to severe ptosis. One must consider both a child’s use of chin position and brow recruitment in addition to eyelid measurements when considering the impact of ptosis on a child.

Finally, all surgical approaches should be considered by a surgeon when addressing ptosis. While all techniques will lift the eyelid, the trade-off of the likelihood for success with the risk for corneal exposure are major considerations when choosing a surgical procedure. Sometimes the goal for a functional improvement knowing a cosmetic improvement cannot be achieved is all that can be accomplished. One should consider the options of internal and external approaches, as well as suspension techniques for each and every patient and not just have a one technique to ptosis surgery.

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References

  1. Anderson RL, Dixon RS. The role of Whitnall's ligament in ptosis surgery. Arch Ophthalmol. 1979;97(4):705–7.

    Article  CAS  PubMed  Google Scholar 

  2. Heher KL, Katowitz JA. Pediatric ptosis. In: Pediatric oculoplastic surgery. New York: Springer; 2002. p. 253–88.

    Chapter  Google Scholar 

  3. Anderson RL, Beard C. The levator aponeurosis: attachments and their clinical significance. Arch Ophthalmol. 1977;95(8):1437–41.

    Article  CAS  PubMed  Google Scholar 

  4. Collin J, Beard C, Wood I. Experimental and clinical data on the insertion of the levator palpebrae superioris muscle. Am J Ophthalmol. 1978;85(6):792–801.

    Article  CAS  PubMed  Google Scholar 

  5. Lecture M, Werb A. The upper lid-structure and restructure. Orbit. 1992;11(2):63–73.

    Article  Google Scholar 

  6. Kuwabara T, Cogan DG, Johnson CC. Structure of the muscles of the upper eyelid. Arch Ophthalmol. 1975;93(11):1189–97.

    Article  CAS  PubMed  Google Scholar 

  7. Berke R, WADSWORTH JA. Histology of levator muscle in congenital and acquired ptosis. AMA Arch Ophthalmol. 1955;53(3):413–28.

    Article  CAS  PubMed  Google Scholar 

  8. Crisponi L, Deiana M, Loi A, et al. The putative forkhead transcription factor FOXL2 is mutated in blepharophimosis/ptosis/epicanthus inversus syndrome. Nat Genet. 2001;27(2):159.

    Article  CAS  PubMed  Google Scholar 

  9. McMullan TF, Collins AR, Tyers AG, Robinson DO. A novel X-linked dominant condition: X-linked congenital isolated ptosis. Am J Hum Genet. 2000;66(4):1455–60.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Krepelova A, Simandlova M, Vlckova M, Kuthan P, Vincent AL, Liskova P. Analysis of FOXL2 detects three novel mutations and an atypical phenotype of blepharophimosis-ptosis-epicanthus inversus syndrome. Clin Exp Ophthalmol. 2016;44(9):757–62.

    Article  PubMed  Google Scholar 

  11. Whitman MC, Engle EC. Ocular congenital cranial dysinnervation disorders (CCDDs): insights into axon growth and guidance. Hum Mol Genet. 2017;26(R1):R37–44.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Pratt SG, Beyer CK, Johnson CC. The Marcus Gunn phenomenon: a review of 71 cases. Ophthalmology. 1984;91(1):27–30.

    Article  CAS  PubMed  Google Scholar 

  13. Spaeth EB. The Marcus Gunn phenomenon: discussion, presentation of four instances and consideration of its surgical correction. Am J Ophthalmol. 1947;30(2):143–58.

    Article  CAS  PubMed  Google Scholar 

  14. Iliff C. The optimum time for surgery in the Marcus Gunn phenomenon. Transactions-Am Acad Ophthalmol Otolaryngol Am Acad Ophthalmol Otolaryngol. 1970;74(5):1005.

    CAS  Google Scholar 

  15. Duke-Elder S. Normal and abnormal development; congenital deformities. Syst Ophthalmol. 1964;3:648–50.

    Google Scholar 

  16. Pearce FC, McNab AA, Hardy TG. Marcus Gunn jaw-winking syndrome: a comprehensive review and report of four novel cases. Ophthalmic Plast Reconstr Surg. 2017;33(5):325–8.

    Article  PubMed  Google Scholar 

  17. Shah KP, Mukherjee B. Efficacy of frontalis suspension with silicone rods in ptosis patients with poor Bell's phenomenon. Taiwan J Ophthalmol. 2017;7(3):143.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Clark TJ, Klejch WJ, Wang K, et al. Hering’s law in congenital ptosis: evaluation of the contralateral response to unilateral congenital ptosis repair. Ophthalmic Plast Reconstr Surg. 2018;34(3):284–90.

    Article  PubMed  Google Scholar 

  19. Callahan M, Beard C. Surgery for levator maldevelopment ptosis. In: Callahan MA, Beard C, editors. Beard’s ptosis. 4th ed. Birmingham: Aesculapius Publishing Company; 1990. p. 113–67.

    Google Scholar 

  20. Harrad R, Graham C, Collin J. Amblyopia and strabismus in congenital ptosis. Eye. 1988;2(6):625.

    Article  PubMed  Google Scholar 

  21. Ptosis FS. Ophthalmic plastic surgery. 3rd ed. New York: Grune & Stratton; 1963. p. 294–345.

    Google Scholar 

  22. Waller R. Evaluation and management of the ptosis patient. In: Mccord C, editor. Oculoplasic surgery. New York: Raven press; 1981.

    Google Scholar 

  23. Iliff C. Problems in ptosis surgery. In: Rycroft PV, editor. Corneoplastic surgery. Oxford, UK: Pergamon; 1969. p. 5–8.

    Google Scholar 

  24. Matthews D. Congenital ptosis. Corneo-plastic surgery. Oxford, UK: Pergamon; 1969. p. 15–29.

    Google Scholar 

  25. Beard C. A new treatment for severe unilateral congenital ptosis and for ptosis with jaw-winking. Am J Ophthalmol. 1965;59(2):252–8.

    Article  CAS  PubMed  Google Scholar 

  26. Painter SL, Hildebrand GD. Topical timolol maleate 0.5% solution for the management of deep periocular infantile hemangiomas. J Am Assoc Pediatr Ophthalmol Strabismus. 2016;20(2):172–4. e171

    Article  Google Scholar 

  27. Putterman AM, Urist MJ. Müller muscle-conjunctiva resection: technique for treatment of blepharoptosis. Arch Ophthalmol. 1975;93(8):619–23.

    Article  CAS  PubMed  Google Scholar 

  28. Kang S, Seo JW, Ahn CJ, Esmaeli B, Sa H-S. Intraoperative lagophthalmos formula for levator resection in congenital ptosis. Br J Ophthalmol. 2019;103(6):802–4.

    Article  PubMed  Google Scholar 

  29. Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol. 2001;119(5):687–91.

    Article  CAS  PubMed  Google Scholar 

  30. Kennedy RH, Mills CR, Brown P (2006) Risk of Infectious Disease Transmission Through Use of Allografts. In: Guthoff R., Katowitz J.A. (eds) Oculoplastics and Orbit. Essentials in Ophthalmology. Springer, Berlin, Heidelberg. https://doi.org/10.1007/3-540-29969-6_1.

  31. Brown P, Gibbs C Jr, Rodgers-Johnson P, et al. Human spongiform encephalopathy: the National Institutes of Health series of 300 cases of experimentally transmitted disease. Ann Neurol. 1994;35(5):513–29.

    Article  CAS  PubMed  Google Scholar 

  32. Kennedy RH, Hogan RN, Brown P, et al. Eye banking and screening for Creutzfeldt-Jakob disease. Arch Ophthalmol. 2001;119(5):721–6.

    Article  CAS  PubMed  Google Scholar 

  33. Wilson ME, Johnson RW. Congenital ptosis: long-term results of treatment using lyophilized fascia lata for frontalis suspensions. Ophthalmology. 1991;98(8):1234–7.

    Article  CAS  PubMed  Google Scholar 

  34. Esmaeli B, Chung H, Pashby RC. Long-term results of frontalis suspension using irradiated, banked fascia lata. Ophthal Plast Reconstr Surg. 1998;14(3):159–63.

    Article  CAS  PubMed  Google Scholar 

  35. Mehta A, Garg P, Naik M, Kumari A. Congenital ptosis repair with a frontalis silicon sling: comparison between Fox's single pentagon technique and a modified Crawford double triangle technique. J Am Assoc Pediatr Ophthalmol Strabismus. 2017;21(5):365–9.

    Article  Google Scholar 

  36. Ruban J, Mallem M, Tabone E, Donne C. A new biomaterial in surgery of ptosis with frontalis suspension: wide pore PTFE. J Fr Ophtalmol. 1995;18(3):207–19.

    CAS  PubMed  Google Scholar 

  37. Katowitz JA. Frontalis suspension in congenital ptosis using a polyfilament, cable-type suture. Arch Ophthalmol. 1979;97(9):1659–63.

    Article  CAS  PubMed  Google Scholar 

  38. Rizvi SAR, Gupta Y, Yousuf S. Evaluation of safety and efficacy of silicone rod in tarsofrontalis sling surgery for severe congenital ptosis. Ophthalmic Plast Reconstr Surg. 2014;30(1):11–4.

    Article  PubMed  Google Scholar 

  39. McLeish WPB, Anderson R. Congenital blepharotopsis surgery. In: Mauriello JA, editor. Unfavorable results of eyelid and lacrimal surgery. Boston: Butterworth/Heinemann; 2000. p. 135–46.

    Google Scholar 

  40. Wagner RS, Mauriello JA Jr, Nelson LB, Calhoun JH, Flanagan JC, Harley RD. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology. 1984;91(3):245–8.

    Article  CAS  PubMed  Google Scholar 

  41. Simon GJB, MacEdo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140(5):877–85.

    Article  PubMed  Google Scholar 

  42. Crawford J. Repair of ptosis using frontalis muscle and fascia lata: a 20-year review. Ophthalmic Surg Lasers Imag Retina. 1977;8(4):31–40.

    CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Ophthalmology, Children’s Hospital of Boston, Harvard University, Boston, USA

    Alexandra T. Elliott

  2. The Children, Wynnewood, PA, USA

    William R. Katowitz

  3. Tufts University, Boston, MA, USA

    Katrinka L. Heher

  4. The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    James A. Katowitz

Authors
  1. Alexandra T. Elliott
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  2. William R. Katowitz
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  3. Katrinka L. Heher
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  4. James A. Katowitz
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Corresponding author

Correspondence to William R. Katowitz .

Editor information

Editors and Affiliations

  1. Department of Ophthalmology, Oregon Health & Science University Department of Ophthalmology, Portland, OR, USA

    Daniel Albert

  2. Massachusetts Eye and Ear, Boston, MA, USA

    Joan Miller

  3. Department of Ophthalmology, University of Illinois at Chicago Department of Ophthalmology, Chicago, IL, USA

    Dimitri Azar

  4. Department of Ophthalmology, Harvard Medical School, Boston, MA, USA

    Lucy H. Young

Section Editor information

  1. No affiliation provided

    Michael Chiang

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Elliott, A.T., Katowitz, W.R., Heher, K.L., Katowitz, J.A. (2020). Pediatric Ptosis. In: Albert, D., Miller, J., Azar, D., Young, L.H. (eds) Albert and Jakobiec's Principles and Practice of Ophthalmology. Springer, Cham. https://doi.org/10.1007/978-3-319-90495-5_275-1

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  • DOI: https://doi.org/10.1007/978-3-319-90495-5_275-1

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  • Print ISBN: 978-3-319-90495-5

  • Online ISBN: 978-3-319-90495-5

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