Pediatric Ptosis Repair: Frontalis Suspension
Roshni Ranjit-Reeves, MD
Frontalis suspension is the procedure of choice for patients with significant ptosis with poor levator function (Fig. 38.1). Often, it is performed to prevent and/or treat amblyopia due to obstruction of the visual axis (deprivation amblyopia) and/or significant induced astigmatism (refractive amblyopia) secondary to the eyelid position. Surgery may also be performed to alleviate a chin up head position, which can interfere with gross motor development (sitting in an infant and walking in a toddler or older child). While the primary goal of the procedure is to improve visual function, aesthetics and facial symmetry should also be addressed.
Indication for procedure: Significant ptosis with poor levator palpebrae superioris function (<4 mm).
PATHOPHYSIOLOGY OF POOR LEVATOR FUNCTION
Congenital:
Idiopathic (most common).
Blepharophimosis-Ptosis-Epicanthus Inversus syndrome (BPES) (see chapter 41).
Double elevator palsy (monocular elevation deficiency).
Duane retraction syndrome (see Chapter 52)
Marcus-Gunn jaw winking (trigemino-oculomotor/maxillopalpebral synkinesis).
FIGURE 38.1. Bilateral congenital ptosis in a 5-year-old boy. Notice use of brow and lack of lid crease (courtesy of Laura B. Enyedi, MD).
Rare congenital disorders.
Abetalipoproteinemia.
Congenital fibrosis of the extraocular muscles (CFEOM).
Moebius syndrome (Congenital oculofacial paralysis).
Refsum disease.
Myogenic:
Kearns-Sayre syndrome.
Myotonic dystrophy.
Oculopharyngeal muscular dystrophy.
Neurogenic:
Cranial nerve III palsy.
Endocrine exophthalmos.
Eyelid apraxia.
Muscular dystrophy.
Myasthenia gravis, occasionally, after maximal medical therapy.
Progressive supranuclear palsy.
Traumatic:
Contact lens intolerance.
Eyelid foreign body.
Eyelid laceration.
Orbital fracture.
Mechanical:
Tumors.
Primary tumors (ie, capillary hemangioma).
Metastasis.
Infection:
Preseptal cellulitis.
Orbital cellulitis.
Chalazion/hordeolum.
Wait at least 6 months in traumatic ptosis for recovery of levator palpebrae superioris function to allow for appropriate surgical planning.
HISTORY
Age of onset.
Progressive vs stable.
Static vs variable.
Family history.
History of strabismus or amblyopia.
Recent trauma or ophthalmologic surgical procedure.
Associated findings—lagophthalmos when sleeping, use of brow or head position.
Gross motor development (ie, determine if head position interfering with sitting or walking).
Old photo evaluation for comparison.
PREOPERATIVE ASSESSMENT
Complete eye examination.
Visual acuity—assess specifically for amblyopia, which can be bilateral or unilateral.
External exam—assess for chin up head position and/or use of brow to elevate the lids. Assess blink and lagophthalmos.
Use of the brow and/or a compensatory head position can indicate that the child is trying to gain binocularity and use the ptotic eye in unilateral cases.
Blowing a quick puff of air in a baby’s face is a good way to assess the blink.
Confrontation visual fields—assess for ptosis affecting the superior field.
Ocular motility and alignment—assess all positions of gaze, especially upgaze. Assess for strabismus, which may accompany ptosis or may occur as a result of amblyopia.
The superior rectus may be abnormal in cases of congenital ptosis. Superior rectus function is critical for a normal Bell response. Abnormal function of the superior rectus may predispose to exposure keratopathy. Positioning an infant prone is a good way to assess eye elevation and superior rectus function. Eye elevation can be difficult to elicit even in normal infants.
Pupils—assess for anisocoria. In Horner syndrome, there is usually mild ptosis and good levator function, in addition to miosis, on the affected side.
Anterior segment—assess for preoperative exposure keratopathy. Perform Schirmer testing if possible.
Cycloplegic refraction—assess for with-the-rule astigmatism, which can cause refractive amblyopia and may require spectacle treatment. Astigmatism secondary to ptosis may or may not improve postoperatively.
Fundus examination—look for abnormalities of the optic nerve and retina as those findings may be helpful in determining if the ptosis is associated with an underlying condition.
Obtain preoperative photos for documentation of ptosis, insurance approval of surgery, and intraoperative guidance on height and contour of lids.
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