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
and surgically unique challenge of cataracts.
Posterior polar cataracts also present dilemmas
in preoperative evaluation, surgical
management, and IOL fixation. Aappropriate
pre-operative assessment and surgical planning
is needed to increase the successful outcome.
Blepharoptosis, also referred to as ptosis, is
the inferior displacement of the upper eyelid. 1
An MRD1 of 2 mm or less is thought to
2
represent clinically significant ptosis. It is a
loss, in most cases superior visual field and
reduce visual acuity especially at night. 1
It is estimated to develop in 7.9 of 100.000
children. The total prevalence of congenital
3
ptosis in general population is 0.18–1.41%. It
was the most prevalent form of ptosis, occurring
in 1 in 842 births.4
.This abnormality can occur from congenital
or acquired causes. As the most common type of
childhood ptosis, congenital ptosis usually
occurs due to poorly developed levator
palpebrae muscle or myogenic causes, which
affects the contraction and relaxation of muscle
5
fibers. The other possible cause of congenital
ptosis is neurogenic origin, including congenital
oculomotor nerve palsy, congenital Horner's
syndrome, and congenital fibrosis of the
extraocular muscles (CFEOM)4.
Ptosis manifestations range from mild eyelid
drops to severe ones. Most congenital ptosis
caused by maldevelopment of the levator muscle
is characterized by decreased levator function,
lid lag, and, sometimes, lagophthalmos. The
upper eyelid crease is often absent or poorly
formed, especially in patients with more severe
ptosis.1 Congenital ptosis can induce refractive
problems such as myopia, anisometropia and
amblyogenic astigmatism, strabismus, and
abnormal torticollis which will affect the visual
function and quality of life2,3. Early diagnosis
and timely treatment of patients with congenital
ptosis are important.
Ptosis treatment remains a challenging
procedure. Many aspects are needed to consider
before doing the surgery, for example, surgical
technique choices; the timing of the procedure;
corneal and refractive status before and after
surgery.3 Here, we report a child with unilateral
congenital ptosis and discuss the other possible
technique of surgery.
Case report
A 77 years old man came to the Royal
Taruma Eye Clinic with the chief complaint of
decreasing of vision of the left eyes since year
ago. He complained the declining of vision
seems progressive and
having visual problems such as doubled
vision, glare, visual loss worsening with reading
and at night, strabismus, abnormal head posture,
headache, and neck pain. Prior to his age, he had
no history of visual problems, orbital trauma
history, and developing mass at the eyelid.
There was no family history of the same
symptom. He had no prior orbital surgery
history. His labour was when the 38th week of
pregnancy through normal delivery ,birth weight
was 2600 gram and no complication during
delivery. Immunization history was complete.
No abnormalities for the growth and
development history.
General Examination Physical examination
of both eyes showed best-corrected visual acuity
(BCVA) 1.0 with S+0.50 in the right eye (RE)
and BCVA 1.0 with S+0.25 in the left eye (LE).
There was congenital ptosis of the right upper
eyelid. Margin-reflex distance1 (MRD1) was
+0.5 mm, MRD2 5 mm, Palpebral Fissure (PF)
5.5 mm, upper eyelid crease 4 mm, Levator
Function 6 mm, lagophthalmos (-), eyelid lag
(-), Left eye upper eyelid higher than right eye in
downgaze, fatigue test (-) and Bells phenomenon
(+). There was no palpable mass at the eyelid.
Left palpebral showed normal parameters.
Ocular mobility was free to all directions.
Hirschberg test showed orthophoria. The cornea
was clear with normal level of tears. The
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
and anisometropic amblyopia are needed to be
treated immediately3.
Many surgical techniques can be used to treat
ptosis. The choices for mild ptosis (2 mm) with
good LMF function (≥10 mm) are Fasanella-
Servat and Müller resection. Moderate ptosis (≥
2 mm) with good LMF is treated with levator
reinsertion while the moderate function is
levator resection. Frontalis suspension surgery
or frontalis sling is used for severe ptosis (≥4
mm) with poor LMF (≤ 4 mm)6,7.
In this case report, the used technique was
frontalis suspension surgery due to severe ptosis
(MRD -2 mm) and poor LFM with good Bell’s
phenomenon. Despite good functional and
cosmetic outcomes, Skaat et al. found a higher
reoperation rate of frontalis suspension (29.3%)
compared to levator resection (10.4%) and
Fasanella-Servat (29.3%)8. It was supported by a
retrospective study by Ho, Wu, & Tsai that
showed poorer preoperative MRD (OR 0.64;
P= .04) and treatment with frontalis suspension
(OR, 5.86; P < .001) as significant risk factors
for recurrence9.
The selection of material for frontalis
suspension also contributes to recurrence. The
material options used for the frontalis
suspension surgery are autologous origin (eg.
fascia lata) and non-autologous origin (eg.
silicone rods, polytetrafluoroethylene (PTFE)).
Fascia lata is superior to silicone rods and PTFE
due to a significantly lower recurrence rate but
only can be applied for ages greater than three
years old due to incomplete development of
fascia lata10. Despite the superiority of fascia
lata, some surgeons prefer to use non-autologous
materials due to the efficiency of time, effort,
and no additional scar. A study by Mattout,
Fouda, & Hemeda suggested a combination of
silicone and green braided polyester suture to
lower the recurrence rate11. In this case report,
the fascia lata material was chosen for its
durability and minimal immune reaction. A 7 cm
fascia lata was harvested from the right thigh to
be used as the sling and the wound was closed
by subcutaneous suture technique. A newer,
minimally invasive technique called endoscope-
assisted fascia lata harvest (EAFH) can be an
alternative method to harvest an adequate length
of fascia lata with a small thigh scar12.
Some postoperative complications can
emerge, for example: under or overcorrection,
dermatochalasis, peaking of the lid, lid lag,
asymmetric skin crease, conjunctival prolapse,
corneal abrasion, exposure keratopathy,
2,13,14
amblyopia, and reintervention. Therefore, a
detailed pre-operative evaluation and discussion
about outcome expectations with the patient are
needed to be done well.
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 functional outcome: a report of 162 cases.
satisfaction. Can J Ophthalmol. 2013;48(2):93–8.
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Daftar Pustaka Associated With Surgical Outcomes in
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Therapeutic Algorithm for Congenital
2. Marenco M, Macchi I, Macchi I, Galassi E,
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