This patient's findings were consistent with unilateral, isolated congenital ptosis. The patient had no other ocular or systemic findings associated with the ptosis, and he had no palpable masses in the upper eyelid that could cause a secondary ptosis.
Because the patient had begun to develop a fixation preference for the right eye, the decision was made to intervene surgically to prevent the development of amblyopia. Given the poor levator function on the left side, a Supramid sling procedure was chosen. Consent was obtained from the mother, and the patient underwent an uncomplicated Supramid sling procedure on the left side shortly thereafter.
The patient returned for a post-operative visit one week later and then at 4 months after the surgery. At his four month follow up visit, his lid position was noted to be improved and his eyelid margin was above the visual axis. (See Figure 2.) He had been seen by his pediatric ophthalmologist in the interim and was noted to have equal fixation with both eyes; his patching regimen was therefore discontinued. While there was still some difference in eyelid position between the two sides, the goal of reversing his amblyopia had been achieved. The mother was advised that further surgery may be necessary in the future to address any eyelid asymmetry.