Congenital ptosis in childrenPtosisIf left untreated, congenital ptosis in children could potentially lead to amblyopia — many parents are unaware of this.
During screenings or pediatric visits, parents are often told to "wait and observe for a while," but many worry whether it is truly safe to leave things as they are. In fact, congenital drooping of the eyelid is not merely a cosmetic or aesthetic concern; it can have an extremely serious impact on a child's visual development. So, in what situations should surgery be performed urgently, and in what situations should we wait for the child to grow? This article thoroughly explores the information that parents should know about congenital ptosis in children — from its causes, amblyopia risk, surgical options, and long-term postoperative outcomes.
What is congenital ptosis? — Understanding the causes of drooping eyelids at birth
Congenital ptosis is a condition in which one or both upper eyelids are abnormally drooped at birth or within the first year of life. Epidemiological data show an incidence of approximately 5.9 per 100,000 people (Marenco et al. 2017). Approximately 70–77.7% are unilateral (Marenco et al. 2017), and males account for 64.3% (Marenco et al. 2017).
The most common cause is underdevelopment of the "levator palpebrae superioris," the muscle that lifts the upper eyelid. During fetal development, fibrous tissue and adipose tissue infiltrate in place of normal striated muscle fibers, causing the muscle to lose its original contractile strength and become unable to adequately raise the eyelid.
While ptosis often appears as an isolated symptom, it can be associated with systemic diseases such as congenital fibrosis of the extraocular muscles (CFEOM), Marcus Gunn jaw-winking syndrome, Duane syndrome, and Horner syndrome.
Why ptosis must not be left untreated — amblyopia risk and timing
When does amblyopia occur?
A child's vision develops gradually as clear images from the external world are transmitted to the brain. If the eyelid obstructs the field of vision during this sensitive period, normal visual stimuli do not reach the brain, and vision remains underdeveloped. Amblyopia develops in approximately 20% of cases of congenital ptosis.
- Deprivation amblyopia:The eyelid physically covers the pupil, blocking light from entering the eye and directly impeding visual development. This can become apparent as early as 17 months after birth (Weaver et al. 2018).
- Astigmatism from compression:The weight of the eyelid continuously exerts pressure on the cornea, causing corneal distortion and inducing high astigmatism.
Children unconsciously adopt compensatory postures — such as pushing the chin upward or strongly raising the eyebrows. In bilateral patients, chin-up posture was observed in 74.6% and eyebrow-raising posture in 47.9%.
Urgency varies based on how much the eyelid covers the pupil
If the eyelid completely covers the pupil, early surgical intervention is strongly recommended even at a very early stage such as 6 months after birth (Weaver et al. 2018).
If the pupil center is clearly visible and visual development is not significantly impaired, surgery is generally deferred until approximately 3 to 5 years of age to avoid the risks of general anesthesia (Weaver et al. 2018). Regular monitoring for amblyopia and strabismus is essential during the waiting period.
Types of surgery — Levator aponeurosis advancement vs. frontalis suspension
Levator aponeurosis advancement / Levator shortening:Indicated when the levator muscle retains reasonable function (movement of 5 mm or greater). The aponeurosis is shortened or advanced and sutured to the tarsal plate, physically enhancing the muscle's lifting force. Recurrence rates tend to be low.
Frontalis suspension:The most standard procedure for severe cases with minimal levator function (4 mm or less). The tarsal plate is connected to the frontalis muscle via sling material beneath the skin, mechanically elevating the eyelid using the eyebrow-raising muscle.
Surgical selection rationale shown by Cochrane review
The Cochrane Library (2019, Rosenberg) conducted a systematic review comparing materials. Three RCTs involving a total of 160 patients were analyzed (Rosenberg et al. 2019).
The conclusion was that the sample size was too small to definitively determine "which material is superior." Materials must be selected carefully based on patient age and condition.
Postoperative course — recurrence risk and long-term data
Seven independent risk factors for recurrence:
- Surgery performed before age 1 (odds ratio 4.92 (Skinner et al. 2010))
- Severe ptosis preoperatively
- Insufficient eyelid elevation postoperatively
- Selection of frontalis suspension procedure (odds ratio 5.86 (Skinner et al. 2010))
- Surgical site infection (odds ratio 9.45× [Skinner et al. 2010])
- Postoperative entropion (odds ratio 11.25×)
- Conjunctival prolapse (odds ratio 7.10×)
The reason recurrence risk jumps to approximately 5× in surgery before age 1 is that during the growth process where the orbit reaches about 90% of adult size by age 5, the fixed material is pulled and becomes lax.
Congenital vs. acquired — how to distinguish and manage differently
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Summary of this article
- Pay close attention to the risk of amblyopia:Congenital ptosis carries a risk of causing amblyopia in approximately 20% of cases, and if the pupil is obscured, early surgical intervention is necessary even within the first few months of life.
- Surgical timing:If vision is not affected, it is standard to wait until around 3–5 years of age to prevent recurrence due to growth.
- Surgical technique and recurrence:Surgery before age 1 or frontalis suspension carries high long-term recurrence risk. Levator advancement shows no recurrence in 76.7% at 10 years.
- Congenital vs. acquired:Lid lag when looking downward is a finding unique to congenital ptosis. Acquired causes include prolonged contact lens use.
"Seek immediate care if any of these apply" checklist
- The eyelid covers the center of the pupil or beyond
- Your child constantly tilts the chin upward when watching TV or objects, or raises the eyebrow abnormally and forcefully
- Only one eye shows sagging eyelid, with extreme asymmetry in how widely the left and right eyes open
- The child squints, avoids eye contact, or has a strong habit of narrowing the eyes
If you have any concerns, please feel free to consult with us.
References
- Weaver et al. 2018. Current management of childhood ptosis. Curr Opin Ophthalmol. 2018DOI
- Marenco et al. 2017. Clinical presentation and management of congenital ptosis. Clin Ophthalmol. 2017DOI
- Rosenberg et al. 2019. Types of materials for frontalis sling surgery for congenital ptosis. Cochrane Database Syst Rev. 2019DOI
- Unknown et al. 2010. Congenital Blepharoptosis Repair. Plast Reconstr Surg. 2010DOI
Author of this article
Hiromitsu NakamuraPhysician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
With research presentation experience at domestic and international academic conferences, also involved in technical guidance and education across Zetith Beauty Clinic. Specializes in precision aesthetic medicine based on anatomical principles, pursuing natural results tailored to each individual's skeletal structure and tissues.