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Droopy eyelids in children

Ptosis is upper droopy eyelids and can occur in children. Ptosis comes from the Greek word “to fall or to drop”. Lots of structures can be ptotic; you could have ptotic eyebrows, ptotic eyelids, ptotic breasts, even ptotic tummy, etc. However, ptosis used as a single work most often applies just to the eyelids. It can be cosmetic or functional, in which case it interferes with vision.
Ptosis can be unilateral, bilateral or a little bit on both sides and asymmetrical. Ptosis can occur in children in which case it is called congenital. The congenital ptosis in children can interfere with the development of their vision, and so that has to be monitored by an orthoptist and paediatric ophthalmologist. Their eyes have to be tested for glasses to make sure they are not long sighted and do not have an associated squint and their eye movements have to be examined to ensure there is not an unusual type of squint present which is only seen in certain positions. Usually, congenital ptosis is distinguished by having dystrophic fatty muscles which do not function well and so there is not much pull on the eyelid, so it does not lift very far, and the skin crease is poorly formed.
The indication for the oculoplastic surgeon to do surgery for congenital ptosis is when it is interfering with the child’s vision. This is functional ptosis surgery. If the upper droopy eyelid is starting to cover the pupil or they are adopting an abnormal head posture with a chin up position to see out, this indicates that they have a functional problem. They may also try and lift their little eyebrows with their forehead muscle to seek to see out better. Again this is an indication of a functional eyelid problem.
Congenital ptosis can be operated on as young as three weeks old if it is covering the pupil and showing no sign of lifting. When a child is very tiny, and the droopy eyelids marked, and the levator function is reduced, a sling operation is done with a material such as silicone or Prolene. When the child is older, it is much easier to get a measure of the levator function, and as long as the vision is developing well, we can wait until they are aged about 3 or 4 years before doing the surgery. This gives an opportunity for all the eye tests to be done, for the fundus to be examined, for the refraction for glasses to be checked and for the vision to be regularly measured by an orthoptist as well as to exclude a squint. Once it is established that there is just a unilateral or bilateral ptosis, the oculoplastic surgeon will operate when they are between the ages of 3 and four before going to school.
In my next blog, I shall tell you about children’s ptosis surgery.

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