DROOPING EYELID (PTOSIS) IN CHILDREN


Ptosis or blepharoptosis is a drooping of the upper eyelid. It may affect just one or both eyelids and can range from very slight to covering the entire eye. Sometimes ptosis is present at birth; and in other cases, it occurs later in life due to injury or disease. Ptosis is usually treated with surgery.
SIGNS & SYMPTOMS:
The most obvious sign of ptosis in children is the drooping lid itself. Doctors assess the severity of the eyelid droop by taking precise measurements of the eyelid and eye opening.
Your child may have one or all of the following:
  • Drooping of one or both eyelids
  • Amblyopia (interference with their vision, if the ptosis is severe).
  • Head tilt: Children with ptosis often tip their heads back into a chin-up position to see. Over many years, this may cause deformities in the head and neck.
WHY SEE A PAEDIATRIC OPHTHALMOLOGIST?
The droopy eyelid may droop only slightly. The real problem comes in when it covers the pupil. This can affect the vision in that eye. This "vision blocking" can lead to amblyopia (lazy eye).

Very importantly to note is that other associated problems, that are not as obvious as the droopy lid itself, can also lead to amblyopia. These are astigmatism, an abnormal shape of the eye.

If amblyopia is not treated early in childhood, it can lead to permanent poor vision, so it is important to have your child’s eyes assessed by an ophthalmologist as soon as the problem is noticed.

POSSIBLE CAUSES
In most children, the droopy lid is present from birth (congenital). It may be due to ahereditary condition or simply a problem in the way the upper eyelid developed.

Although it is usually an isolated problem, a child with congenital ptosis may also have:
  • Eye movement abnormalities
  • Muscular diseases
  • Eyelid tumours
  • Neurological disorders
  • Refractive errors



TREATMENT
Mild ptosis is often not noticeable when your child is awake and full of energy. It can, though, become more obvious as they get tired. Not all cases of ptosis require surgery and some can just be monitored but you should discuss all options with your child's eye specialist.

If a child is born with significant ptosis, treatment is often necessary to allow for normal vision to develop. If it is not corrected, amblyopia (lazy eye) may develop. If left untreated, amblyopia can lead to permanent vision loss.

The treatment for childhood ptosis is usually surgery, although there are a few rare disorders that can be treated with medications.

The ophthalmologist will assess your child and determine whether or not surgery is needed, based on:
  • The age of your child
  • Involvement of 1 or both eyelids
  • Measurement of the eyelid height
  • The eyelid's lifting and closing muscle strength
  • Observation of the eye's movements.
During surgery the eyelids are lifted either by tightening the levators (the muscles used to lift the eyelid) or if these muscles are extremely week a procedure can be done to use the forehead muscles to aid in lifting the eyelid this is known as a brow suspension. The ophthalmologist will also assess if any other treatment is needed such as:
  • Glasses for astigmatism or refractive errors
  • Patching for amblyopia
  • Surgical repair is usually very successful in improving the appearance and function of the eyelid, although the eyelids may not appear perfectly symmetrical.

    Sometimes more than one operation may be required.
MORE INFORMATION ON THE POSSIBLE CAUSES:
The most common congenital causes are: Isolated congenital ptosis, blepharophimosis syndrome, the Marcus Gunn jaw-winking syndrome and Myasthenia Gravis.

Isolated Congenital Ptosis:
The muscle in the upper eyelid that helps to lift the lid is called the LevatorPalpabrae Superioris. In some children, this muscle does not develop properly, and so it cannot lift the lid adequately.

This condition is called Isolated Congenital Ptosis and usually occurs in one eye only. The parent might notice that the crease in the eyelid skin as it reflects off the eyeball, is absent. They may also notice that when their child looks down, the eyelid doesn’t lower normally. This condition is treated with surgery to help the muscle function correctly.

Blepharophimosis Syndrome (BPES):
This is a hereditary condition in which not only does the eyelid muscle not develop properly, but the entire area of both the upper and the lower eyelids are affectedas well. This condition occurs in both eyes at the same time.

The opening of the eye is smaller than normal and both upper lids droop. There is a fold of skin over the corner of each eye closest to the nose, and the lower eyelid edges might turn outwards away from the eyeball.

Here, the treatment is also surgical.

The Marcus Gunn jaw-winking syndrome:

It occurs when the nerves that supply one of the muscles used to chew, becomes abnormally connected to the nerve that controls the levator muscle. This is a rare condition that usually occurs in one eye.

When the child moves their lower jaw in almost any movement like opening their mouth, chewing or sucking, the drooping eyelid rapidly lifts. This can look like a wink. When the child looks down, this fast flutter of the upper eyed becomes worse.

An important consideration is that the child may also have poor vision and a squint. So it should not be ignored. If the child’s vision is affected, it may need to be corrected with spectacles. Some cases require surgery. Ptosis can also develop later on in life due to an injury or disease.

Myasthenia gravis:
This is an autoimmune condition, in which the body attacks the connections between the nerves and the muscles. In the case of ptosis, this means that the muscles that open the eyelids are affected.

This can occur transiently in a newly delivered baby, if the mum suffers from myasthenia gravis. The mother’s antibodies may cross the placenta and temporarily affect the child. It usually lasts for about four weeks and does not increase the child’s life-time risk of developing the condition.

A child can be born with this condition having developed antibodies themselves.Both eyelids droop and this is usually noticed in the first year of life.

Juvenile myasthenia gravis:

Here it makes its presence known in the teenage years. It is more common in girls and the condition is usually life-long. The signs usually appear gradually in both eyelids or just one at a time. The teenager or parent may notice that the drooping becomes worse after exercise or towards the end of the day. The child may complain of decreased vision.

Several investigations such as testing for the fatigability of the muscles and blood tests can be done. Medication is the mainstay of treatment. Surgical repair is very seldom considered as the state of the disease can fluctuate dramatically over time.

Horner syndrome:

This is a combination of signs and symptoms caused by the damage to a nerve pathway that travels from the brain, via the neck, to the eyes and face on the same side of the body.

The most common causes of Horner syndrome in children include: Injury to the neck or shoulders during delivery, a defect of the aorta present at birth or a tumor of the hormonal and nervous systems, known as a Neuroblastoma.

The child, on the affected side, may present with a drooping eyelid, a smaller pupil that doesn’t respond well to light, an eye that is paler than the “normal” side, a lack of sweating on the face and a lack of reddening of the face during physical exertion, emotional distress or heat.

The most important course of action is to have the underlying cause diagnosed. Once this is done, treatment specific to the source, can be initiated.

The ophthalmologist will assess the child’s vision and provide assistance if required.

Congenital Third Nerve palsy: adgadgfsgdfgf

This may be a developmental or acquired cause of a drooping eyelid. The congenital form is rare and the acquired causes are too numerous to describe here. The child may present with a drooping eyelid, abnormal movement of the eyes and an enlarged pupil.

It is vital to have these children referred to an ophthalmologist as soon as the condition is noticed. They are at a high risk of losing the vision in the affected eye and so need early and aggressive treatment.
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