Introduction. Congenital blepharoptosis represents a significant ophthalmoplastic pathology that substantially impacts the quality of life for patients and their families. Epidemiologically, blepharoptosis frequently coexists with other pathological conditions, predominantly of neurological origin. The presence of concomitant pathologies may considerably influence both surgical strategy and postoperative results. Objective. To evaluate the impact of somatic pathology on the severity of congenital blepharoptosis in pediatric patients and on surgical outcomes. Materials and methods. A retrospective analysis was conducted on 113 pediatric patient records who underwent surgical correction of congenital blepharoptosis of varying severity. Patients were divided into two groups: somatically healthy ( n = 90) and with concomitant somatic pathology ( n = 23), including congenital cardiovascular, renal, or central nervous system anomalies. Criteria for preoperative surgical planning included: unilateral or bilateral ptosis, degree of ptosis, levator muscle function (LMF), margin-reflex distance 1 (MRD1), palpebral fissure width at the pupillary center, lateral and medial limbus, presence of lagophthalmos, height and presence of eyelid crease, and involvement of accessory muscles (e.g., brow mobility). Surgical interventions comprised levator resection and superior tarsal muscle resection. Postoperative follow-up was performed inpatient on days 1, 3, and 7, and outpatient at 1, 3, 6, and 12 months. Results. In the somatically healthy group, unilateral blepharoptosis predominated, whereas bilateral involvement was more common in the group with somatic pathologies. Statistical analysis revealed a significant correlation between bilateral blepharoptosis and the presence of somatic comorbidities ( p = 0.025). Analysis of ptosis severity noted significant differences: grade 3 ptosis was observed in 51.43 % of the second group compared to 28.07 % in the first. Concomitant ophthalmic conditions were distributed as follows: amblyopia (28.89 % in group I and 39.13 % in group II), astigmatism (34.44 % and 47.83 %, respectively), and strabismus (esoor exotropia) in 20.00 % and 17.39 %. The operative time was notably longer in group II: average levator resection duration was 53.7 minutes versus 36.2 minutes in group I, with ICU stay averaging 23.6 minutes versus 16.2 minutes. Unsatisfactory outcomes necessitating reoperation were recorded in 23.33% of group I and 30.43% of group II, with no cases of persistent lagophthalmos. Conclusion. The presence of concomitant somatic pathology in pediatric patients with congenital blepharoptosis necessitates meticulous preoperative evaluation in a multidisciplinary hospital setting, with a high level of anesthetic support to optimize surgical planning and outcomes.

Purpose: To compare sutureless conjunctiva-sparing Müllerectomy (CSM) versus Müller muscle–conjunctival resection (MMCR) in pediatric ptosis repair. Methods: This is a retrospective comparative study of pediatric patients with mild ptosis and near-normal levator function who underwent either sutureless CSM or MMCR at a single academic institution. Children aged below 18 years with unilateral or bilateral ptosis and levator function ≥10 mm were enrolled in this study. Patients with prior ptosis repair were excluded. Primary outcomes were change in margin–reflex distance 1 (ΔMRD1) and postoperative symmetry; secondary outcomes included operative time, postoperative complications, and reoperation. Results: Thirty-three operative eyelids met the inclusion criteria: 13 underwent sutureless CSM, and 20 underwent traditional Müllerectomy. Age at surgery, preoperative MRD1, and levator function did not significantly differ between cohorts. Both cohorts were predominantly comprised of patients with congenital myogenic ptosis. Mean ΔMRD1 was 1.2 mm in the sutureless CSM group versus 1.3 mm in the MMCR group ( P =0.56), and symmetry at last follow-up was 0.7 mm versus 0.8 mm ( P =0.74). Operative time was significantly shorter for sutureless CSM (7.5 versus 13.5 min per eyelid; P =0.001). Reoperation rates (33% versus 18%; P =0.35) and complication incidence (none in both groups) were comparable. Conclusions: Sutureless CSM achieves similar eyelid elevation and symmetry to MMCR while reducing operative time, supporting its adoption as a safe and efficient alternative in pediatric ptosis repair.

Clinical Manifestations and Genetic Insights Into Congenital Myasthenic Syndrome-22 in Pediatric Patients.

Giant cell arteritis (GCA) is a medical emergency in adults older than 50 years because treatment delay may lead to irreversible visual loss or other ischemic injury. We report a 71-year-old man with schistosomal cirrhosis who presented with fever, persistent headache, scalp tenderness, and subsequent right-sided ptosis. The diagnostic process was difficult because his early manifestations were nonspecific, inflammatory abnormalities could initially be interpreted in the context of chronic liver disease, and temporal artery ultrasound was unrevealing. PET/CT subsequently demonstrated diffuse fluorodeoxyglucose uptake involving the bilateral subclavian, carotid, superficial temporal, and peripheral arteries, supporting a diagnosis of large-vessel GCA. After high-dose methylprednisolone was started, the patient experienced rapid symptomatic relief together with marked improvement in inflammatory markers; methotrexate was later added as a glucocorticoid-sparing agent. Management required additional caution because of cirrhosis, abnormal liver biochemistry, and severe hypertension. This case emphasizes three practical points: unilateral ptosis may be an early neuro-ophthalmic signal of GCA even in the absence of overt visual loss, a negative temporal artery ultrasound does not rule out disease when extracranial involvement predominates, and PET/CT can provide decisive evidence when initial cranial imaging fails to explain a highly suspicious presentation.

This case series aims to highlight Horner's syndrome, a clinical diagnosis of unilateral ptosis, miosis, and anhidrosis, as a rare complication of posterior spinal surgery in pediatric patients. In this series, we present three pediatric patients who developed Horner's syndrome after surgical correction of scoliosis involving the cervicothoracic region. Case 1 is a 12-year-old female with DiGeorge syndrome who underwent revision surgery with extension into the cervical spine after developing proximal junctional kyphosis 2years after her index spinal fusion procedure. Case 2 is a 9-year-old girl who had posterior spinal fusion for progressive thoracic congenital scoliosis. Case 3 is a 4-year-old female with Klippel-Feil syndrome who underwent correction of a cervicothoracic curve and hemivertebrae excision. Postoperatively, all three patients were noted to have either unilateral miosis or ptosis, with an eventual diagnosis of acquired Horner's syndrome. This case series demonstrates that Horner's syndrome is a rare complication after a posterior spinal fusion in the pediatric population. Each case highlights that the oculosympathetic pathway can be susceptible to injury during deformity correction, specifically near the cervicothoracic region, whether from traction injury or overt nerve root transection.

PurposeAlthough aponeurotic ptosis is typically bilateral, the specific risk factors for unilateral cases remain unclear. Thus, we aimed to identify factors associated with unilateral aponeurotic ptosis by comparing eyes that underwent surgery with their non-ptotic contralateral counterparts.Patients and MethodsThis retrospective observational clinical study included patients who underwent levator resection for aponeurotic ptosis at the Fukui University Hospital, between April 1, 2014, and March 31, 2024, were included. The contralateral non-ptotic eye served as the internal control. The presence of risk factors, such as a history of filtering surgery, prostaglandin analog use, cataract surgery, and vitrectomy, was compared between the operated and fellow eyes using McNemar’s test. Firth’s penalized logistic regression analysis was performed to identify independent risk factors for unilateral aponeurotic ptosis.ResultsSixty-eight patients were included in the analysis, with both eyes (136 eyes in total) evaluated. Glaucoma filtering surgery, prostaglandin analog use, and cataract surgery were significantly more frequent in operated eyes (P = 0.004, P = 0.045, and P = 0.002, respectively). Multivariate analysis showed that filtering surgery [odds ratio (OR) = 17.6, P = 0.009] and cataract surgery (OR = 2.07, P = 0.046) were independently associated with unilateral ptosis.ConclusionPrior glaucoma filtering and cataract surgeries are significant risk factors for the development of unilateral aponeurotic ptosis.

Oculomotor nerve palsy with pupil involvement is considered a neurosurgical emergency due to the high suspicion of compressive pathology such as aneurysm or hematoma. We present the case of a 73-year-old female with pupil-involving partial CN III palsy following head trauma, presenting with persistent unilateral ptosis (5 mm), dilated non-reactive pupil, and absent Bell’s phenomenon, reflecting impaired ocular protective motor coordination. Notably, neuroimaging studies revealed no radiologically detectable compressive lesion. Despite this, the clinical risk remained significant due to the well-established diagnostic priority of the pupil sign over imaging in early trauma. The patient underwent a comprehensive Ayurvedic management protocol, including systemic purification (Takrapanam, Snehapanam, Virechana), localized neuro-rehabilitative therapies (Karna Pooranam, Nasyam, Shirodhara), and ophthalmic rejuvenation (Netra Tarpanam and Putapaka). Complete functional resolution of ptosis and restoration of pupillary reactivity was achieved with visual acuity improving from 3/60 to 6/36 in the right eye and from 6/36 to 6/12 in the left eye. This case highlights the potential of integrative Ayurvedic intervention as a rehabilitation strategy in post-traumatic cranial nerve injuries, particularly in subtle micro compressive presentation under undetected on imaging.

To observe and measure the levator aponeurosis (LA) in patients with unilateral aponeurotic ptosis (AP) using high-frequency (22MHz) B-mode ultrasound with a water balloon. Thirty-two unilateral APs were recruited. Palpebral fissure height (PFH), levator function (LF), and marginal reflex distance 1 (MRD1) of the affected eyes and the normal control eyes were measured. Sagittal ultrasound images of the central upper eyelid of both eyes were captured, and ultrasound indicators such as the thickness of the LA, the distance from the upper border of the tarsal plate to the septoaponeurosis junction (TJD), the thickness of the tarsal plate (TTP), the height of the tarsal plate (HTP), and the distance from the insertion point of the LA to the lower border of the tarsal plate (ITD) were measured in the ultrasound images. The PFH, LF, MRD1, and thickness of the LA were all significantly lower in the affected eyes compared to the normal control eyes. The TJD value in the affected eyes was significantly greater than that in the normal control eyes. In contrast, the other three measurement parameters-namely, TTP, HTP, and ITD-showed no significant intergroup differences. High-frequency (22MHz) B-mode ultrasound is a noninvasive and highly effective tool for visualizing and measuring the LA. In cases of unilateral AP, the LA exhibits reduced thickness compared to that of normal control eyes.

Ophthalmoplegia with ptosis represents a heterogeneous group of disorders that pose significant diagnostic challenges. We report the case of a 16-year-old adolescent boy presenting with ophthalmoplegia and unilateral ptosis. This case underscores the critical role of comprehensive clinical evaluation and standardized therapeutic protocols in the diagnosis and management of this disorder. Readers will walk through the stepwise diagnostic approach to arrive at the leading diagnosis, with a review of the possible differential diagnoses for the relevant clinical manifestations.

Although severe ocular complications following plastic and cosmetic surgeries or treatments are relatively uncommon, early diagnosis and intervention are essential for improving prognosis. This study investigates optimized strategies for the effective identification and management of these complications. A retrospective study was conducted on 11 patients (10 female, 1male, mean age: 38.5) with severe ocular complications after plastic and aesthetic surgery or procedures treated at a single referral center between January 2014 and December 2024. Types of ocular complications and their etiologies, early diagnosis and management experiences were analyzed and summarized. 1 case of irreversible vision loss from ophthalmic artery occlusion after nasal augmentation with hyaluronic acid. 1 case of visual impairment from ophthalmic artery occlusion after autologous fat filler in the forehead. Delayed optic nerve injury with visual impairment after blepharoplasty in 2 cases. Unilateral vision loss after forehead fat accumulation correction in 1 case. Corneal damage causing visual impairment after upper eyelid ptosis surgery in 2 cases. Ocular micro-embolism and skin necrosis after hyaluronic acid filler in the forehead in 2 cases, without vision loss. Unilateral ptosis with reversible vision loss after hyaluronic acid filler in the forehead in 1 case, resolved with hyaluronidase. Corneal chemical burns and vision issues from iodophor entering the eye during eyelid blepharoplasty in 1 case, following treatment with epidermal growth factor, there was no significant improvement in vision. A flowchart for the prevention and management of severe ocular complications was developed and the risk factor for each case of severe complication was summarized. Severe ocular complications from plastic and aesthetic surgeries are uncommon and need specialized knowledge for early detection and treatment to improve outcomes. Without this, they can cause irreversible damage or be life-threatening. Plastic and cosmetic surgeons must be well-versed in recognizing, evaluating, and treating rare but potentially serious ocular complications following surgeries or treatments. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

To assess and compare the conjunctival bacterial flora in patients with congenital ptosis (CP) to that of healthy individuals. The study included 38 patients with CP and 42 healthy control subjects. Conjunctival cultures were collected using a cotton-tipped swab applied to the inferior conjunctival fornix. The samples were inoculated into blood agar, eosin methylene blue agar, chocolate agar for bacteria, and Sabouraud dextrose agar medium for fungi. The culture positivity rate was 68.4% in CP and 47.6% in the control group (P<0.001). Additionally, there was a significant difference in culture positivity between the eyes of patients with unilateral ptosis (P=0.039). In the CP group, the most common found microorganism was Staphylococcus epidermidis at 23.67%, followed by Haemophilus species at 21.04%, and Corynebacterium species at 15.78%. In the control group, Staphylococcus epidermidis and Corynebacterium species were both the most commonly isolated microorganisms, each accounting for 19.04%. More than one species of bacteria was grown in the cultures of 36.84% and 23.80% of the CP and control subjects, respectively. Gram-negative bacteria were more common in CP than in control subjects (P=0.031). Culture positivity is significantly higher in the ptotic eyes of CP. Potentially pathogenic microorganisms are more frequently isolated from the CP group compared with the healthy control group.

Paragangliomas are neuroendocrine tumors that often present as solitary tumors. In this case report, we describe a patient with multiple head and neck paraganglioma associated with a mediastinal paraganglioma. The patient was a 46-year-old male with a history of surgical removal of a mass from the right side of the neck, who presented with dysphonia lasting two months, hoarseness, vague chest pain, and unilateral ptosis. CT angiography of the carotid arteries and thoracic aorta revealed multiple findings, including a well-defined enhancing mass measuring 33 × 39mm in the aorto-pulmonary prevascular space, a grade I carotid body tumor on the left side of the neck, vagal paragangliomas on the right side of the neck, and a glomus jugulare tumor on the right side. These findings were collectively suggestive of multiple paragangliomas. The patient subsequently underwent surgical resection of the mediastinal tumor, and pathological examination confirmed the diagnosis of paraganglioma. This report details a rare case of paraganglioma with multiple head, neck, and mediastinal involvement, emphasizing the need for thorough evaluation and genetic assessment in atypical presentations.

BackgroundWhile various surgical techniques have been developed for blepharoptosis correction, the frontalis suspension technique is commonly applied in cases of poor levator function or prior surgical history. This study evaluates the efficacy of a modified frontalis muscle flap suspension technique in achieving satisfactory outcomes for severe or recurrent blepharoptosis with poor levator function.MethodsA retrospective study conducted from January 2014 to January 2017 reviewed the medical records of 47 patients with a mean age of 17.3 ± 9.17 years at 108 Military Central Hospital, Ha Noi, Vietnam. These patients were diagnosed with moderate to severe blepharoptosis (marginal reflex distance 1, MRD1 0–2 mm) with poor levator function (<4 mm) and underwent modified C-shaped frontalis muscle flap suspension. The outcomes were measured by the sum of functional and cosmetic grading scales at 6- and 12-month follow-ups. Postoperative complications were also noted.ResultsThere are 40 patients (85.1%) who have unilateral ptosis and 7 (14.9%) who have bilateral ptosis. Forty-seven patients (87%) had severe ptosis, while seven (13%) had moderate ptosis. A history of frontalis sling surgery was present in 38.9% of patients. At the 12-month follow-up, 37 patients (78.7%) had good outcomes, 9 patients (19.1%) had fair outcomes, and 1 patient (2.1%) had poor outcomes that underwent surgical revision.ConclusionOur analysis of the modified C-shaped frontalis muscle flap suspension technique demonstrates its efficacy in treating moderate and severe blepharoptosis, particularly in cases with poor levator function and prior surgical history.

Although Müller muscle-conjunctival resection (MMCR) is generally considered safe with a low incidence of complications, the authors report a rare and previously undocumented event: a full-thickness eyelid defect. A 63-year-old male patient with unilateral aponeurotic ptosis underwent MMCR with a 9mm resection using a Putterman clamp. While the initial postoperative eyelid position was satisfactory, a horizontally 7mm and vertically 5mm full-thickness defect was identified following suture removal on postoperative day 10. This defect was not apparent when the patient's eyes were closed or in the primary position, but became noticeable during downgaze. Revision surgery was performed four days later with complete functional and cosmetic recovery. This case highlights the importance of meticulous intraoperative technique and postoperative monitoring, even in minimally invasive procedures like MMCR, to avoid rare but significant complications.

Purpose:To evaluate the effect of unilateral Mueller’s muscle conjunctival resection (MMCR) on the contralateral upper eyelid position in patients without preoperative Hering’s effect.Methods:This retrospective study analyzed 33 patients who underwent unilateral MMCR for mild to moderate ptosis at Shiley Eye Institute, University of California, San Diego. Patients with additional procedures or preoperative Hering’s effect were excluded. Margin Reflex Distance (MRD1) was measured using Image J software from standardized digital images. Five masked researchers independently measured MRD1, with the average of the middle three values used for analysis.Results:The mean preoperative and postoperative MRD1 of the operated eye were 1.20 mm (SD 0.92) and 3.35 mm (SD 0.83), respectively. For the nonoperated eye, preoperative MRD1 was 3.15 mm (SD 0.85) and postoperative MRD1 was 3.28 mm (SD 0.8). There was a statistically significant improvement in the operated eyelid MRD1 (P < 0.001) but no statistically significant change in the nonoperated eyelid position (P = 0.704). One patient (3%) experienced an MRD1 drop >1 mm in the fellow eye. Thirty-two patients (97%) had ≤1 mm difference between operated and nonoperated eyelids postoperatively. Interestingly, 18 patients (54.5%) showed a paradoxical increase in contralateral MRD1 (mean 0.66 mm, range 0.02–2.39 mm). All patients achieved acceptable symmetry without requiring additional procedures.Conclusion:MMCR effectively corrects mild to moderate unilateral upper eyelid ptosis with minimal impact on the contralateral eyelid in patients without preoperative Hering’s effect. While the procedure resulted in no significant changes to the contralateral eyelid in 97% of cases, the unexpected finding of paradoxical contralateral lid elevation in over half the patients warrants further investigation.

Barakat syndrome is a rare autosomal dominant genetic disease characterized by a triad of symptoms: hypoparathyroidism, sensorineural hearing loss and kidney dysplasia. The disease is associated with a mutation in the GATA3 gene located on the short arm of chromosome 10 (10p15), which leads to impaired embryonic development of the parathyroid glands, auditory system and kidneys. The article presents a clinical case of a patient with Barakat syndrome, in whom, in addition to the main clinical manifestations, unilateral ptosis was also detected. After birth, the boy showed signs of acute renal damage and hypocalcemia, which required intensive therapy and correction of electrolyte disorders. The uniqueness of this case lies in the presence of a previously undescribed mutation in the GATA3 gene, as well as in the diagnosis of the disease at the age of 6 months. In order to diagnose Barakat syndrome early, a multidisciplinary approach is important, and timely treatment significantly improves the condition of patients.

PurposeTo evaluate the effect of the levator muscle-conjoint Fascial Sheath Complex Suspension on ocular biometric parameters and refractive status in children with congenital blepharoptosis.MethodsWe reviewed the clinical records of 68 patients with congenital blepharoptosis who attended our hospital from 2021 to 2023 and underwent ptosis surgery with detailed examination. The changes of corneal topography and refractive characteristics before and 1 month, 3 months, 6 months after surgery were compared and analyzed.ResultsBefore surgery, ptosis eyes had statistically significant flatter flat keratometry (P = 0.015), thicker subfoveal choroidal thickness (P = 0.021), higher astigmatic magnitude(P = 0.006) than non-blepharoptosis eyes. The 1-month postoperative steep keratometry and the astigmatic magnitude were significantly higher than the preoperative values in unilateral ptosis (P = 0.032, P = 0.014), without affecting astigmatic power vectors and central corneal thickness (P > 0.05); The astigmatic magnitude at 3 months after surgery were higher than the preoperative values in unilateral ptosis (P = 0.042). In all patients, the postoperative change of astigmatic magnitude was greatest in severe ptosis.ConclusionsPtosis repair surgery for congenital ptosis seems to cause increase of steep K value and astigmatism over early postoperative period but no refraction alteration over the long-term postoperative period. A significant myopic shift was observed at the 6-month postoperative follow-up in severe unilateral ptosis.

Myasthenia gravis (MG) is an autoimmune disorder characterized by weakness and fatigability of skeletal muscle. Juvenile myasthenia gravis (JMG) is MG in patients under the age of 18. The incidence is estimated to be 5.9 - 8.7 per million person-years. In ocular JMG, a subtype of JMG, symptoms are isolated to eye muscles. This case report presents the diagnostic journey of a 3-year-old non-Asian female from Virginia, USA, who initially exhibited symptoms consistent with ocular JMG. The patient’s early symptoms, including eyelid drooping and watery eyes, were initially misattributed to eye irritation and upper respiratory infection symptoms. However, suspicion for JMG emerged as her condition progressed to include bilateral ptosis, facial weakness, and other bulbar symptoms. The diagnostic process involved interdisciplinary collaboration and continued revisal of the differential diagnoses as symptoms evolved. The diagnosis was ultimately confirmed with a positive JMG panel, including elevated acetylcholine receptor (AChR) binding and modulating antibodies. This case highlights the importance of considering JMG in the differential diagnosis of ocular and bulbar symptoms, and the challenges associated with diagnosis of rare diseases. Tailored management strategies, including acetylcholinesterase inhibitors and potential immunosuppressive agents, should be considered based on individual patient needs. Keywords : Myasthenia Gravis, Neuromuscular Disorders, Ptosis, Autoimmune, Facial Weakness.

Certain neurological conditions may closely resemble acute stroke in their clinical presentation, complicating the diagnostic process and potentially delaying appropriate treatment. This report presents a clinical case that illustrates the diagnostic difficulties encountered at the onset of Miller Fisher syndrome(MFS), a rare variant of Guillain-Barré syndrome(GBS). A 42-year old male patient initially exhibited symptoms commonly associated with ischemic stroke in the posterior circulation, including unilateral ptosis, double vision, dizziness, difficulty swallowing, reduced voice strength, ataxia, and limb weakness. Despite these signs, diffusion-weighted magnetic resonance imaging(DWI-MRI)revealed no evidence of acute cerebral ischemia. The development of ophthalmoplegia and absence of reflexes raised suspicion of an alternative neurological disorder. Subsequent serological testing confirmed the presence of anti-GQ1b antibodies, and treatment with intravenous immunoglobulins was initiated, resulting in significant clinical improvement. This case highlights the importance of maintaining a broad differential diagnosis in patients with atypical neurological symptoms and emphasizes the role of comprehensive evaluation in avoiding misdiagnosis. Awareness of such presentations can aid in earlier recognition of Miller Fisher syndrome and improve outcomes for individuals with rare autoimmune neuropathies.Keywords:strokemimics,Guillain-Barresyndrome,MillerFishersyndrome,GQ1b antibodies.

Unilateral ptosis in a patient with thyroid eye disease: A case report