Case Report :

Successful Management of Polar Cataract - a Case Report

Willy Yahya , Jennifer , Josiah Irma

Abstract :

Introduction: Congenital ptosis is the most common type of childhood ptosis. It manifests in
mild to severe forms that can induce amblyopia, astigmatism, strabismus, and psychological issue
in children.

Case Report: A 7 years old boy came to the Siloam Eye Clinic with drooping of the right upper
eyelid since birth. Prior to his age, his parents denied any visual problems and orbital disorders.
Physical examination showed Right Eye BCVA 1.0 with S+0.50 and Left Eye BCVA 1.0 with
S+0.25; good ocular mobility and MRD1 +0.50 mm. He was diagnosed with unilateral congenital
ptosis and underwent ptosis surgery with frontalis muscle suspension using autogenous tensor
fascia lata. The post-surgery outcome reveals a good result and no complications.

Discussion: The technique selection is determined by the clinical presentation and surgeon
experience. In this report, frontalis suspension surgery was chosen due to severe ptosis and poor
LMF. Fascia lata was selected as the material for the sling due to its superiority compared to other
materials.

Conclusion: Neglected congenital ptosis can seriously impact the children's quality of life. Early
diagnosis and treatment are required to preserve good visual development. As the treatment of
choice for this patient, frontalis muscle suspension using autologous tensor fascia lata on
congenital ptosis has excellent results and satisfaction.

Keywords: Congenital ptosis, frontalis suspension surgery, frontal sling, fascia lata

Introduction common cause of reversible peripheral vision

Posterior polar cataract represent a medically loss, in most cases superior visual field and
and surgically unique challenge of cataracts. reduce visual acuity especially at night. 1
Posterior polar cataracts also present dilemmas It is estimated to develop in 7.9 of 100.000
in preoperative evaluation, surgical children. The total prevalence of congenital
management, and IOL fixation. Aappropriate 3
ptosis in general population is 0.18–1.41%. It
pre-operative assessment and surgical planning
was the most prevalent form of ptosis, occurring
is needed to increase the successful outcome.
in 1 in 842 births.4
Blepharoptosis, also referred to as ptosis, is
.This abnormality can occur from congenital
the inferior displacement of the upper eyelid. 1
or acquired causes. As the most common type of
An MRD1 of 2 mm or less is thought to
childhood ptosis, congenital ptosis usually
2
represent clinically significant ptosis. It is a
occurs due to poorly developed levator decreasing of vision of the left eyes since year
palpebrae muscle or myogenic causes, which ago. He complained the declining of vision
affects the contraction and relaxation of muscle seems progressive and
5
fibers. The other possible cause of congenital having visual problems such as doubled
ptosis is neurogenic origin, including congenital vision, glare, visual loss worsening with reading
oculomotor nerve palsy, congenital Horner's and at night, strabismus, abnormal head posture,
syndrome, and congenital fibrosis of the headache, and neck pain. Prior to his age, he had
extraocular muscles (CFEOM)4. no history of visual problems, orbital trauma
Ptosis manifestations range from mild eyelid history, and developing mass at the eyelid.
drops to severe ones. Most congenital ptosis There was no family history of the same
caused by maldevelopment of the levator muscle symptom. He had no prior orbital surgery
is characterized by decreased levator function, history. His labour was when the 38th week of
lid lag, and, sometimes, lagophthalmos. The pregnancy through normal delivery ,birth weight
upper eyelid crease is often absent or poorly was 2600 gram and no complication during
formed, especially in patients with more severe delivery. Immunization history was complete.
ptosis.1 Congenital ptosis can induce refractive No abnormalities for the growth and
problems such as myopia, anisometropia and development history.
amblyogenic astigmatism, strabismus, and General Examination Physical examination
abnormal torticollis which will affect the visual of both eyes showed best-corrected visual acuity
function and quality of life2,3. Early diagnosis (BCVA) 1.0 with S+0.50 in the right eye (RE)
and timely treatment of patients with congenital and BCVA 1.0 with S+0.25 in the left eye (LE).
ptosis are important. There was congenital ptosis of the right upper
Ptosis treatment remains a challenging eyelid. Margin-reflex distance1 (MRD1) was
procedure. Many aspects are needed to consider +0.5 mm, MRD2 5 mm, Palpebral Fissure (PF)
before doing the surgery, for example, surgical 5.5 mm, upper eyelid crease 4 mm, Levator
technique choices; the timing of the procedure; Function 6 mm, lagophthalmos (-), eyelid lag
corneal and refractive status before and after (-), Left eye upper eyelid higher than right eye in
surgery.3 Here, we report a child with unilateral downgaze, fatigue test (-) and Bells phenomenon
congenital ptosis and discuss the other possible (+). There was no palpable mass at the eyelid.
technique of surgery. Left palpebral showed normal parameters.
Ocular mobility was free to all directions.
Case report Hirschberg test showed orthophoria. The cornea
A 77 years old man came to the Royal was clear with normal level of tears. The
Taruma Eye Clinic with the chief complaint of pupillary size was 3 mm, isocoria, with good
direct and indirect light reflex, and no relative
afferent pupillary defect. Anterior segment
examination of both eyes reveal no
abnormalities.
He was diagnosed with unilateral congenital
ptosis. Ptosis surgery was done with frontalis
muscle suspension using autogenous tensor
fascia lata in general anesthesia. The procedure
begin by harvesting fascia lata around 70 x 15
mm, 10 cm above the lateral supracondylar.
Superior palpebra margin was incised and
dissected around 6 mm until the tarsus. Fascia
lata then sutured to the tarsus and frontalis Picture 1. Pre and 2 weeks Post Frontalis
muscle. Muscle Suspension
Follow up on the 1st day post-surgery, the
palpebral superior was oedema, but the hecting Discussion
was intact and no sign of infection. The MRD1 Blepharoptosis, also referred to as ptosis, is
was 2 mm and FPV 7mm. Patient was given oral the inferior displacement of the upper eyelid. 1 It
and topical antibiotic along with oral analgetic, can be categorized as minimal (1-2 mm),
he was discharge to continue his medication at moderate (3-4 mm) or severe(>4mm). 2
home. This abnormality can occur from congenital
Follow up on the 1st week post-surgery or acquired causes. As the most common type of
showed a slight oedema in the palpebral childhood ptosis, congenital ptosis usually
superior, hecting was in good condition, MRD1 occurs due to poorly developed levator
was 3 mm and FPV 8 mm. During the 2 nd week palpebrae muscle or myogenic causes, which
follow-up, Physical examnination of the right affects the contraction and relaxation of muscle
eye showed a good wound healing, no oedema fibers.5
no sign of infection, MRD 1 was 4 mm, FPV 9 Treatment of ptosis needs to be done
mm. meticulously. The pre-operative evaluation
started with documentation of palpebral baseline
parameters, including MRD1, PF, LFM,
eyebrow elevation, Bell’s phenomenon, and
other coexisting conditions, such as refractive
errors, strabismus, microphthalmia,
pseudoptosis1,4,5. Any deprivational amblyopia years old due to incomplete development of
and anisometropic amblyopia are needed to be fascia lata10. Despite the superiority of fascia
treated immediately3. lata, some surgeons prefer to use non-autologous
Many surgical techniques can be used to treat materials due to the efficiency of time, effort,
ptosis. The choices for mild ptosis (2 mm) with and no additional scar. A study by Mattout,
good LMF function (≥10 mm) are Fasanella- Fouda, & Hemeda suggested a combination of
Servat and Müller resection. Moderate ptosis (≥ silicone and green braided polyester suture to
2 mm) with good LMF is treated with levator lower the recurrence rate11. In this case report,
reinsertion while the moderate function is the fascia lata material was chosen for its
levator resection. Frontalis suspension surgery durability and minimal immune reaction. A 7 cm
or frontalis sling is used for severe ptosis (≥4 fascia lata was harvested from the right thigh to
mm) with poor LMF (≤ 4 mm)6,7. be used as the sling and the wound was closed
In this case report, the used technique was by subcutaneous suture technique. A newer,
frontalis suspension surgery due to severe ptosis minimally invasive technique called endoscope-
(MRD -2 mm) and poor LFM with good Bell’s assisted fascia lata harvest (EAFH) can be an
phenomenon. Despite good functional and alternative method to harvest an adequate length
cosmetic outcomes, Skaat et al. found a higher of fascia lata with a small thigh scar12.
reoperation rate of frontalis suspension (29.3%) Some postoperative complications can
compared to levator resection (10.4%) and emerge, for example: under or overcorrection,
Fasanella-Servat (29.3%)8. It was supported by a dermatochalasis, peaking of the lid, lid lag,
retrospective study by Ho, Wu, & Tsai that asymmetric skin crease, conjunctival prolapse,
showed poorer preoperative MRD (OR 0.64; corneal abrasion, exposure keratopathy,
2,13,14
P= .04) and treatment with frontalis suspension amblyopia, and reintervention. Therefore, a
(OR, 5.86; P < .001) as significant risk factors detailed pre-operative evaluation and discussion
for recurrence9. about outcome expectations with the patient are
The selection of material for frontalis needed to be done well.
suspension also contributes to recurrence. The
material options used for the frontalis Conclusion
suspension surgery are autologous origin (eg. Neglected congenital ptosis can seriously
fascia lata) and non-autologous origin (eg. impact the children's quality of life. Early
silicone rods, polytetrafluoroethylene (PTFE)). diagnosis and treatment are required to preserve
Fascia lata is superior to silicone rods and PTFE good visual development. As the treatment of
due to a significantly lower recurrence rate but choice for this patient, frontalis muscle
only can be applied for ages greater than three suspension using autologous tensor fascia lata
on congenital ptosis has excellent results and functional outcome: a report of 162 cases.
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