A 5-year-old child presents with ptosis of the left upper eyelid with a margin-reflex distance-1 (MRD1) of −1 mm (pupil covered), absence of a lid crease, and levator excursion of 3 mm. Which surgical approach is most appropriate?

• A Frontalis suspension with autogenous fascia lata ✓
• B Müller muscle conjunctival resection (Putterman procedure)
• C Levator aponeurosis advancement
• D Tarsectomy (Fasanella-Servat operation)

Explanation

Severe congenital ptosis with poor levator function (excursion ≤ 4 mm) is managed by frontalis suspension, which uses the frontalis muscle action to elevate the lid. In children under 5-7 years, silicone rods or temporary materials may be used pending fascia lata maturity; in older children, autogenous fascia lata is preferred. Levator advancement is for moderate ptosis with levator excursion ≥ 5 mm. The Müller muscle procedure is for mild ptosis with good phenylephrine response.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.