My child has a droopy eyelid – should I be worried?
Noticing a droopy eyelid, or ‘ptosis’, can be very concerning to a parent when they see their baby or child.
Childhood ptosis develops due to a range of conditions and in many respects is more complicated than adult ptosis. Droopy eyelids in adults are due to mostly genetic causes and just due to old age which is called involutional ptosis.
However, in children, the ptosis can be caused by many different things. Babies can be born with ptosis, termed ‘congenital ptosis’. Most baby’s eyelids are wide open either at birth or shortly afterwards. If either one or two eyelids appear not to be opening this is likely to be caused by a weakness of the muscle of the upper lid, most commonly because this muscle is not fully developed. Less commonly it can be the result of a problem with the nerve that supplies the upper lid.
Congenital ptosis in a newborn can be exceedingly worrying
It can be worrying not only to the parents but also to the doctor who has to make sure that your child can see well and can develop their vision. The reason is that if the eyelid is occluding or covering the visual axis on one or both eyes your child’s vision may not fully develop.
If your child has congenital ptosis, you should arrange to see a paediatric ophthalmologist or an oculoplastic surgeon with interest in paediatrics, i.e. children. They will examine your child’s eyes to make sure that they are healthy and normal with good red reflexes, good retinas and no significant need for glasses.
If your child is very young, say 3 weeks to 6 months, and the ptosis is getting in the way of the visual axis; it is challenging to tell how well the child is seeing because their vision is still at a very early stage of development and is very difficult to measure. However, it is critical that light enters the eye adequately, in order to develop the visual pathways between the retina and the brain. Sometimes we do surgery to lift eyelids in children who are very young. We do that when they have what is called poor levator function ptosis, in other words, their muscles are quite fatty and underdeveloped, making them ineffective at lifting the eyelids.
In this group of infants, we will do a frontalis suspension which is where the strength for the eyebrow muscle (called the frontalis muscle) is used to help lift the eyelids by slinging a small piece of Prolene or silicone between the eyebrow and the eyelid to help raise it. That means that your child will then be reliant on using their eyebrow muscles to help see out of the affected eye, but they will not otherwise be able to develop their vision. Usually, this type of ptosis is bilateral, but sometimes it can be unilateral.
Other children may have less marked ptosis, more often on one side than the other, where they can still see out of the eye. The ptosis is more likely to be a cosmetic issue, although when tired parents rightly note that the droop of the lid can become more marked and there often still remains concern that vision can be affected. The paediatric ophthalmologist, or the oculoplastic surgeon with a particular interest in children’s eyelids, will monitor their eyelid measurements and their vision to ensure it develops normally.
Monitoring vision in a baby or young child also involves the orthoptist, who will help by measuring vision using special techniques depending on the age of the child, and check that there is no squint. The doctor will also check that your child does not need glasses. As long as the vision is developing well, which may require a little bit of patching to help it, then your child may not need surgery with quite so much immediacy as the infant whose eyelid or eyelids are covering the visual axis.
We like best to see your child on several occasions to maximise the accuracy of the eyelid measurements and the visual assessment. Then we choose to operate with your agreement round about the age of 3 to 4 years so that their eyelids are cosmetically satisfactory for when they go to school and when they are more aware of their appearance.
As you can understand all surgery on children has to be done under a short general anaesthetic, and we always use a paediatric anaesthetist who is experienced in children’s anaesthesia. We operate in the hospital near Clinica London – either the Portland Hospital or the Harley Street Clinic – which both admit children under the age of 12. They have all the facilities for the care of children having general anaesthesia. The surgery is done as a day case, and afterwards, I just put some ointment in the eye which you continue doing at home. It is very rare that I put an eye pad on.
Children’s eyelids heal very quickly. By the time they come back to see us – between weeks one and two – we have a good idea of how successful the surgery is. Do not be alarmed if it looks as though the eyelid is hanging up a bit when they look down because the eyelid will be quite stiff, to begin with, and not flexible or mobile. That will improve with time. Equally, do not be concerned if they cannot entirely close their eyes at night because fortunately there is an excellent eye reflex called the Bells’ Phenomena which helps to protect their eye. So, although you may see a chink of white visible, their eye should be safe.
So if your child has a droopy eyelid, you should get a 30-minute assessment with either a paediatric ophthalmologist Ms Naz Raoof at Clinica London or the oculoplastic surgeon with interest in children Miss Jane Olver also at Clinica London. Naz and I both work closely with the orthoptists at Clinica London Gina Harris and Joe Mc Quillan. They help to measure the visual acuities and determine whether there is a coexistent squint that needs to be treated either with patching or patching and glasses.
We will advise you on when is the best time for surgery. For instance, if you come to see me with your child’s ptosis and they are very young, and it is clear that they have got the risk of amblyopia, then I will lift the eyelid virtually immediately when they are even less than six months old.
However, if they have slight ptosis and are going to need surgery roundabout age 4, I would recommend that Naz Raoof and the orthoptist keep monitoring the visual development and help to reduce the risk of a lazy eye or amblyopia. Then I will see them again nearer to the time we plan to do the surgery. That means it could be a gap of about three or four years before you see me the second time. I will then do the eyelid surgery when it best suits you and your child.