Pediatric Ptosis

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.