A 3-year-old child presents with unilateral complete ptosis since birth. On examination, the levator function is 2 mm and the contralateral lid shows a lag on downgaze. The BEST management is:

• A Fasanella-Servat procedure
• B Levator resection
• C Observation until age 10 for levator strengthening
• D Frontalis sling (brow suspension) ✓

Explanation

Levator function ≤4 mm indicates poor levator action and is a contraindication to levator resection. Frontalis sling connects the eyelid to the frontalis muscle, allowing lid elevation using brow movement; it is the procedure of choice for congenital ptosis with poor levator function. The contralateral lid lag in downgaze is Hering's law sign from bilateral levator co-innervation. Fasanella-Servat (Müller muscle resection) is for mild ptosis (1–2 mm) with good levator function. Observation risks amblyopia from visual axis occlusion.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.