What is the recommended treatment for baby ptosis?

Treatment of Baby Ptosis

The recommended treatment for baby ptosis depends on the severity of the condition and the risk of amblyopia, with surgical intervention indicated primarily when there is risk to visual development. 1, 2

Assessment and Diagnosis

When evaluating ptosis in infants, consider:

• Severity of ptosis: Minimal (1-2mm), moderate (3-4mm), or severe (>4mm) 3
• Levator function: Critical for determining surgical approach
• Visual axis obstruction: Determines risk of amblyopia
• Eyelid crease formation
• Charles Bell phenomenon (eye movement under closed lid)
• Pupillary examination: To rule out Horner syndrome or third nerve palsy 4

Always rule out pseudoptosis and evaluate for associated conditions such as:

• Orbital/periorbital plexiform neurofibromas (in NF1 patients) 1
• Thyroid eye disease
• Neurological conditions

Treatment Algorithm

1. Non-surgical Management

• Observation: For mild ptosis without visual axis obstruction
• Visual monitoring: Regular ophthalmologic follow-up to detect early signs of amblyopia
• Amblyopia treatment: If detected, initiate patching or other appropriate therapy

2. Surgical Management

Timing of surgery:

• Immediate intervention: When severe ptosis obstructs the visual axis and poses risk of amblyopia
• Delayed intervention: For cosmetic concerns without visual impact, can be postponed until 3-5 years of age 2

Surgical technique based on levator function:

• Good levator function (>5mm):

  • Levator muscle resection
  • Fasanella-Servat procedure (for minimal ptosis) 3

• Poor levator function (<5mm):

  • Frontalis suspension using autologous fascia lata (preferred for long-term correction) 5
  • Alternative materials like Mersilene mesh may be considered when fascia lata cannot be harvested 6

Post-surgical Considerations

• Close follow-up: Monitor for under or overcorrection
• Amblyopia surveillance: Continue monitoring for amblyopia development, as it may occur even after successful ptosis correction 6
• Refractive error assessment: Higher incidence of refractive errors in children with congenital ptosis (18.7%) 6
• Strabismus evaluation: Concomitant strabismus is present in approximately 14% of cases 6

Important Considerations

• The success rate for single-operation correction is approximately 71%, with about 20% requiring reoperation 6
• Amblyopia is found in approximately 26% of children with ptosis 6
• Unilateral surgery is generally preferred over bilateral approaches for unilateral ptosis 5
• Direct fixation of sling material to the tarsal plate improves success rates in frontalis suspension procedures 5

Common Pitfalls

• Failing to monitor for amblyopia both pre- and post-operatively
• Overlooking associated conditions like strabismus or refractive errors
• Delaying referral to ophthalmology when visual axis obstruction is present
• Performing surgery without adequate assessment of levator function
• Underestimating the need for long-term follow-up, as complications may develop years after surgery

Early referral to a pediatric ophthalmologist is essential for proper evaluation and management planning, even if surgical intervention is delayed.