Is a patient with left deep amblyopia (lazy eye), bilateral blepharoptosis (drooping eyelids), a history of Photorefractive Keratectomy (PRK), and left glaucoma a candidate for repair of blepharoptosis?

Blepharoptosis Repair in a Patient with Left Deep Amblyopia, Bilateral Blepharoptosis, History of PRK, and Left Glaucoma

Blepharoptosis repair is indicated in this patient as surgery may prevent further visual deterioration and improve quality of life, particularly when ptosis is causing visual field obstruction.

Assessment of Indications

Blepharoptosis repair in this patient should be considered based on several key factors:

1. Amblyopia and Visual Development:

   • Surgery is indicated when blepharoptosis is severe enough to prevent successful amblyopia therapy without surgical correction 1
   • While the patient has deep amblyopia in the left eye, surgical correction of ptosis can still improve visual function and prevent further deterioration

2. Visual Field Obstruction:

   • Bilateral blepharoptosis can cause significant visual field restriction
   • This functional impairment affects quality of life and daily activities
   • Correction can improve peripheral vision even in the amblyopic eye

3. Glaucoma Considerations:

   • Left glaucoma requires ongoing monitoring
   • Ptosis may interfere with proper examination and treatment of glaucoma
   • Improved eyelid position facilitates better glaucoma management

Surgical Planning Considerations

Pre-surgical Evaluation

• Hering's Test: Essential to evaluate for contralateral lid retraction when one ptotic lid is manually elevated 2
  • This helps identify cases where unilateral repair may unmask or worsen contralateral ptosis
  • Particularly important in this bilateral case to determine appropriate surgical approach

Surgical Approach

• Levator Advancement: Recommended as primary approach
  • Operative findings often reveal partial or total disinsertion of the levator muscle from the tarsal plate 2
  • This technique has shown favorable outcomes with minimal recurrence during follow-up

Special Considerations for This Patient

1. History of PRK:

   • PRK history requires special attention to ocular surface protection during and after surgery
   • Ensure adequate lubrication to prevent corneal complications
   • PRK itself may have been performed to address anisometropic amblyopia 1

2. Glaucoma Management:

   • Coordinate with glaucoma specialist for perioperative medication management
   • Consider potential impact of topical medications on wound healing
   • Plan for continued intraocular pressure monitoring

3. Amblyopia Impact:

   • While adult amblyopia is less responsive to treatment, improving visual input may still benefit overall visual function
   • Repair of blepharoptosis may improve quality of life even if visual acuity improvement in the amblyopic eye is limited

Potential Complications and Management

• Undercorrection/Overcorrection: Most common complication

  • Plan for possible adjustment procedure
  • More challenging in amblyopic eye due to difficulty assessing symmetry

• Exposure Keratopathy: Higher risk with history of PRK

  • Aggressive lubrication in postoperative period
  • Consider temporary tarsorrhaphy if severe

• Lagophthalmos: Inability to fully close eyelids

  • Particularly concerning with history of PRK and glaucoma
  • May require lid massage or revision if persistent

Follow-up Protocol

• Initial evaluation at 1 week
• Assess for symmetry, lid position, and ocular surface health
• Monitor for any impact on glaucoma management
• Long-term follow-up to evaluate stability of correction

Conclusion

Blepharoptosis repair is indicated in this patient despite the complex ocular history. The procedure should focus on functional improvement and prevention of further visual deterioration. The surgical approach should be tailored to address the bilateral nature of the condition with careful attention to the patient's history of PRK and glaucoma.