Is repair of blepharoptosis (drooping of the eyelid) justified in a patient with left deep amblyopia (lazy eye), bilateral blepharoptosis, history of Photorefractive Keratectomy (PRK), and left glaucoma?

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

Repair of blepharoptosis is justified and indicated in this patient with left deep amblyopia, bilateral blepharoptosis, history of PRK, and left glaucoma, as surgery is necessary to prevent further visual deterioration and improve visual function. 1

Rationale for Surgical Intervention

• Visual Function Improvement: Blepharoptosis can significantly restrict the visual field and reduce quality of life, particularly when bilateral. Correction can improve peripheral vision and daily functioning 1

• Amblyopia Management: Surgery is specifically indicated when blepharoptosis is severe enough to prevent successful amblyopia therapy. The American Academy of Ophthalmology guidelines state that surgery may be indicated when blepharoptosis occludes the visual axis and is severe enough to prevent successful amblyopia therapy 2

• Prevention of Further Visual Deterioration: Even in patients with established deep amblyopia, addressing the ptosis can prevent further deterioration of vision and potentially allow for some visual improvement 1

Surgical Considerations for This Patient

Pre-existing Conditions Requiring Special Attention

1. Left Deep Amblyopia:

   • The presence of amblyopia is not a contraindication for ptosis repair
   • Amblyopia is found in approximately 26.45% of children with ptosis 3
   • Ptotic eyes have more severe astigmatism and a greater percentage of oblique astigmatism than fellow eyes, which can contribute to amblyopia 4

2. History of PRK:

   • Requires special attention to ocular surface protection during and after surgery
   • Aggressive lubrication in the postoperative period is essential to prevent exposure keratopathy 1
   • Patients with history of keratorefractive surgery require careful monitoring for signs of corneal ectasia 2

3. Left Glaucoma:

   • Coordination with a glaucoma specialist is necessary for perioperative medication management
   • Careful consideration of the impact of topical medications on wound healing 1
   • Monitoring of intraocular pressure during the perioperative period is essential

Surgical Approach

The recommended surgical approach for this patient is levator advancement, as operative findings often reveal partial or total disinsertion of the levator muscle from the tarsal plate 5. This approach is particularly appropriate for:

• Bilateral blepharoptosis requiring correction
• Adult patients with acquired ptosis
• Patients with moderate to good levator function

Postoperative Management

1. Initial Follow-up (1 week):

   • Assess symmetry and lid position
   • Evaluate ocular surface health, particularly important given history of PRK
   • Monitor for any impact on glaucoma management 1

2. Ocular Surface Protection:

   • Aggressive lubrication with preservative-free artificial tears
   • Consider temporary punctal occlusion if dry eye symptoms develop
   • Monitor for exposure keratopathy, especially given history of PRK 1

3. Glaucoma Management:

   • Continue glaucoma medications as directed by glaucoma specialist
   • Monitor intraocular pressure at each follow-up visit

Potential Complications to Monitor

1. Undercorrection or Overcorrection:

   • Most common complication requiring possible adjustment procedures 1
   • May require reoperation in approximately 19.89% of cases 3

2. Exposure Keratopathy:

   • Higher risk with history of PRK
   • Requires aggressive lubrication in the postoperative period 1

3. Lagophthalmos:

   • Inability to fully close eyelids is particularly concerning with history of PRK and glaucoma
   • May require lid massage or revision if persistent 1

4. Astigmatism Changes:

   • Changes in astigmatism axis toward oblique astigmatism can occur after ptosis surgery
   • This can potentially be amblyogenic and requires monitoring 4

In conclusion, repair of blepharoptosis is justified in this patient despite the complex medical history. The benefits of improved visual function and prevention of further visual deterioration outweigh the risks when appropriate perioperative precautions are taken.