Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Evaluation of All Causes of Visual Function Loss in Children With Congenital Blepharoptosis

Ozlem Ural, MD; Mehmet C. Mocan, MD; Ugur Erdener, MD

Abstract

Purpose:

To evaluate the overall frequency of visual function loss in pediatric patients with congenital blepharoptosis.

Methods:

This retrospective study was conducted in a tertiary center. The clinical records of patients younger than 18 years who were diagnosed as having congenital blephroptosis, underwent surgery, and had at least 1 year of postoperative follow-up were evaluated. Visual acuity results, presence of structural eye abnormalities, presence and type of amblyopia and strabismus, and refractive errors were recorded. The Mann–Whitney U test, chi-square test, and stepwise regression analysis were used for statistical analyses.

Results:

The mean final visual acuity was 0.11 ± 0.23 logarithm of the minimum angle of resolution (logMAR) (range: 0.0 to 1.0 logMAR) at the final follow-up visit for 143 eyes of 123 patients (65 male and 58 female). In this cohort, 30 patients (24.4%) had amblyopia and 5 patients (4.1%) had visual loss related to structural eye pathology, amounting to a total of 35 patients (28.5%) with visual function loss. The mean final visual acuities of patients without amblyopia, patients with amblyopia, and patients with organic eye disorders were 0.01 ± 0.03, 0.29 ± 0.28, and 0.55 ± 0.42 logMAR, respectively. Severe blepharoptosis (≥ 4 mm) was present in 25 patients (83.3%) with amblyopia. Deprivational amblyopia was detected in 25 of 36 eyes (69.4%) with amblyopia. Independent risk factors associated with final visual acuity were presence of amblyopia at presentation (correlation coefficient [ß] ± standard error [SE] = −0.29 ± 0.04; P < .001), anisometropia (ß ± SE = −0.27 ± 0.06; P < .001), and ptosis severity (ß ± SE = −0.09 ± 0.04; P = .012). Visual impairment (visual acuity < 20/40) persisted in 11.9% of eyes at the final follow-up.

Conclusions:

Visual function loss was present in one-third of pediatric patients with congenital blepharoptosis. Both amblyopia and structural eye disorders contribute to visual impairment in this patient population. Structural eye pathology contributes independently to 4.1% of visual loss in this clinical setting.

[J Pediatr Ophthalmol Strabismus. 2020;57(2):97–102.]

Abstract

Purpose:

To evaluate the overall frequency of visual function loss in pediatric patients with congenital blepharoptosis.

Methods:

This retrospective study was conducted in a tertiary center. The clinical records of patients younger than 18 years who were diagnosed as having congenital blephroptosis, underwent surgery, and had at least 1 year of postoperative follow-up were evaluated. Visual acuity results, presence of structural eye abnormalities, presence and type of amblyopia and strabismus, and refractive errors were recorded. The Mann–Whitney U test, chi-square test, and stepwise regression analysis were used for statistical analyses.

Results:

The mean final visual acuity was 0.11 ± 0.23 logarithm of the minimum angle of resolution (logMAR) (range: 0.0 to 1.0 logMAR) at the final follow-up visit for 143 eyes of 123 patients (65 male and 58 female). In this cohort, 30 patients (24.4%) had amblyopia and 5 patients (4.1%) had visual loss related to structural eye pathology, amounting to a total of 35 patients (28.5%) with visual function loss. The mean final visual acuities of patients without amblyopia, patients with amblyopia, and patients with organic eye disorders were 0.01 ± 0.03, 0.29 ± 0.28, and 0.55 ± 0.42 logMAR, respectively. Severe blepharoptosis (≥ 4 mm) was present in 25 patients (83.3%) with amblyopia. Deprivational amblyopia was detected in 25 of 36 eyes (69.4%) with amblyopia. Independent risk factors associated with final visual acuity were presence of amblyopia at presentation (correlation coefficient [ß] ± standard error [SE] = −0.29 ± 0.04; P < .001), anisometropia (ß ± SE = −0.27 ± 0.06; P < .001), and ptosis severity (ß ± SE = −0.09 ± 0.04; P = .012). Visual impairment (visual acuity < 20/40) persisted in 11.9% of eyes at the final follow-up.

Conclusions:

Visual function loss was present in one-third of pediatric patients with congenital blepharoptosis. Both amblyopia and structural eye disorders contribute to visual impairment in this patient population. Structural eye pathology contributes independently to 4.1% of visual loss in this clinical setting.

[J Pediatr Ophthalmol Strabismus. 2020;57(2):97–102.]

Introduction

Visual loss is an important concern in pediatric patients with congenital blepharoptosis.1–4 Increased risk of amblyopia in this patient population necessitates frequent physician visits, and is often factored into the surgical decision making of these patients for the correction of eyelid contour.2,5,6 Although stimulus deprivational amblyopia associated with visual axis obstruction is the most widely appreciated type of amblyopia in this setting, refractive and strabismic amblyopia may also coexist and contribute to visual function deficits.1,2,7 Organic ocular pathology such as microphthalmos and anterior segment dysgenetic conditions may also lead to visual impairment in congenital blepharoptosis.8–10

Several prior studies have emphasized the association of amblyopia with congenital blepharoptosis.1–4,7,11 In a previous meta-analysis by Wang et al.,2 22.7% of patients with congenital blepharoptosis had amblyopia, 19.6% had strabismus, and 17.3% had anisometropic refractive errors. The high prevalence of associated ocular disorders often requires co-management of these patients between oculo-plastic surgeons and pediatric ophthalmologists.

Previous studies on visual function abnormalities in children with congenital blepharoptosis limited their analyses to amblyopia-related visual loss in this patient population.1,3,6,7 However, congenital blepharoptosis may also be associated with structural eye problems (eg, microphthalmos or Peters' anomaly) that may independently result in permanent visual impairment.9,10 To the best of our knowledge, the extent of visual function loss related to all forms of visual insults in the setting of congenital blepharoptosis has not been evaluated in a holistic manner in the literature. Thus, the purpose of this study was to evaluate the prevalence of visual function loss in the setting of congenital blepharoptosis that arises secondary not only to amblyopia but to all types of visual insults, including structural eye pathologies.

Patients and Methods

This was a retrospective study undertaken at a tertiary center (Hacettepe University) with approval from the institutional review board. A total of 134 consecutive pediatric patients younger than 18 years diagnosed as having unilateral or bilateral congenital blepharoptosis who had undergone surgical correction of their ptosis and had at least 1 year of postoperative follow-up were included in the study. The clinical parameters included patient demographics, age at presentation, age at surgery, visual acuity, laterality and severity of blepharoptosis, margin reflex distance 1 (MRD1), presence and type of strabismus, refractive error, presence, type, and treatment of amblyopia, and presence of structural eye pathology. Data from the initial examination, first postoperative examination, and final examination were analyzed. Only patients who had their visual acuity tested with a formal Snellen test or the tumbling E test were included in analyses related to visual function. Children who did not have quantitative visual acuity data were excluded from statistical analyses. Visual acuity results were converted to logarithm of the minimum angle of resolution (logMAR) values for statistical calculations. Visual impairment was defined as a best corrected visual acuity (BCVA) of better than 20/40 at distance, as defined in the current World Health Organization International Classification of Diseases-11 coding scheme.

Blepharoptosis was categorized as mild (≤ 2 mm), moderate (> 2 to < 4 mm), and severe (≥ 4 mm) according to ptosis severity based on the criteria described by Freuh.11 Amblyopia was defined as BCVA of worse than 20/25 in bilateral ptosis or a difference between the two eyes of at least two lines in the setting of unilateral ptosis.12 Amblyopia was classified as refractive, strabismic, or stimulus deprivation. Refractive amblyopia was defined as the presence of a visual loss related to anisometropia of 1.50 diopters or greater of cylinder power or spherical equivalent by cycloplegic refraction. Strabismic amblyopia was defined as the presence of visual loss in the setting of strabismus with a fixation preference for one eye without any other associated organic ocular pathology or anisometropia. Deprivation amblyopia was defined as visual loss related to complete or partial obstruction of the pupillary axis by the ptotic eyelid identified during clinical evaluation. A complete response to amblyopia treatment was defined as a final BCVA of 20/25 or better. Partial response to treatment was defined as at least two Snellen lines of improvement in the BCVA but a final BCVA of worse than 20/25.

For statistical analysis, Statistical Package for Social Sciences for Windows (version 20; IBM SPSS Inc., Chicago, IL) was used. The statistical analysis of the study was performed by a biostatistician. Frequency and percentages are given for the nominal data as descriptive statistics. The Kolmogorov–Smirnov test was used to evaluate normal distribution of the datasets. The chi-square or Fisher's exact test was used in comparing categorical measures. The Mann–Whitney U test was used to compare means of the groups. The stepwise regression analysis was used to evaluate the relationship between clinical factors and amblyopia. A P value of less than .05 was set as the level for significance.

Results

The study cohort included 155 eyes of 134 patients (72 male and 62 female) with congenital blepharoptosis. Of the cohort, 143 eyes of 123 patients had visual acuity data available for analysis. The mean age at diagnosis was 7.8 ± 5.8 years and the mean follow-up time was 8.5 ± 6.0 years. Fifty-three patients (43.1%) had right eyelid ptosis, 44 patients (35.8%) had left eyelid ptosis, and 26 patients (21.1%) had bilateral eyelid ptosis. Six of 26 patients with bilateral ptosis underwent ptosis surgery on one side only. Blepharoptosis was categorized as mild in 11 eyes (8.9%), moderate in 49 eyes (39.8%), and severe in 63 eyes (51.2%).

All patients included in the study underwent surgical correction for blepharoptosis. Of the 143 included eyes, 28 eyes (19.6%) required one additional procedure, 3 eyes (2.1%) required two additional procedures, and 1 eye (0.7%) required three additional procedures to correct recurrent blepharoptosis. No eye suffered visual loss related to surgical intervention. Nocturnal lagophthalmos was the only complication observed in 16 of the operated eyes (11.2%). It resolved in all but 2 eyes (1.4%) within the first 3 postoperative months.

In the current study, 98 patients (79.6%) had dystrophic congenital ptosis, 9 patients (7.3%) had Marcus-Gunn syndrome, 10 patients (8.1%) had blepharophimosis syndrome, 2 patients (1.6%) had double elevator palsy, and 4 patients (3.3%) had congenital fibrosis of the extraocular muscles. One patient (0.8%) had an underlying syndromic condition (ie, Möbius syndrome).

The mean final visual acuity of the 123 patients was 0.11 ± 0.23 logMAR (Snellen equivalent = 20/26; range = 0.0 to 1.0 logMAR) at the final follow-up visit. Thirty patients (24.4%) had amblyopia and 5 patients (4.1%) had visual loss related to structural eye pathology, totaling 35 patients (28.5%) with visual function loss. Furthermore, mild to severe visual impairment (defined by BCVA < 20/40) was present in 17 eyes (11.9%) of 13 patients with congenital blepharoptosis.

Amblyopia was detected in 30 of 123 study patients (24.4%). Of the 143 eyes with available visual acuity data, 36 eyes (25.2%) had amblyopia. Refractive amblyopia was detected in 8 eyes (22.2%), strabismic amblyopia in 2 eyes (5.6%), combined refractive and strabismic amblyopia in 1 eye (2.8%), and deprivational amblyopia in 25 eyes (69.4%). Of the 25 eyes with deprivational amblyopia, 16 eyes (44.4%) had purely deprivational amblyopia, 6 eyes (16.7%) had combined refractive and deprivational amblyopia, 2 eyes (5.6%) had combined strabismic and deprivational amblyopia, and 1 eye (2.8%) had refractive, strabismic, and deprivational amblyopia, respectively. All 25 eyes with deprivational amblyopia had severe blepharoptosis with complete obstruction of the visual axis. Among eyes with deprivational amblyopia, 7 eyes (19.4%) had combined deprivational and refractive amblyopia (Table 1).

Comparison of Visual Acuity and Eyelid Measurements in Pediatric Patients With Refractive Versus Deprivational Amblyopia in the Setting of Congenital Blepharoptosis

Table 1:

Comparison of Visual Acuity and Eyelid Measurements in Pediatric Patients With Refractive Versus Deprivational Amblyopia in the Setting of Congenital Blepharoptosis

Patients with deprivational amblyopia had worse initial visual acuity and MRD1 measurements compared to patients with refractive amblyopia (Table 1). All patients with amblyopia were treated with part-time occlusion (varying from 2 to 6 hours of patching). Following part-time occlusion, 13 patients (36.1%) had complete resolution and 7 patients (19.4%) had partial resolution of amblyopia, respectively.

Of the entire patient cohort (N = 134), 7 patients (5.2%) had structural ocular pathologies that resulted in visual impairment. Two patients (28.5%) had microphthalmos, 1 patient (14.2%) had aniridia, secondary glaucoma, and nystagmus, 1 patient (14.2%) had optic atrophy, 1 patient (14.2%) had microcornea, 1 patient (14.2%) had bilateral iris coloboma with congenital disc anomalies, and 1 patient (14.2%) had corneal opacification. Of the 7 patients, 5 patients had quantifiable visual acuity assessments and 1 patient with bilateral optic atrophy had only fix and follow behavior in both eyes.

The mean final visual acuity of patients without amblyopia (n = 88), with amblyopia (n = 30), and with organic eye disorders (n = 5) was 0.01 ± 0.03 (Snellen equivalent = 20/20), 0.29 ± 0.28 logMAR (Snellen equivalent = 20/39), and 0.55 ± 0.42 (Snellen equivalent = 20/70) logMAR, respectively (Table 2). Initial visual acuity of study patients correlated strongly with the final visual outcomes in both eyes with amblyopia (r = 0.661; P < .001) and eyes with organic eye pathology (r = 0.972; P < .001) (Figure 1).

Visual Acuity and Eyelid Measurements of Pediatric Patients With Congenital Blepharoptosis Based on the Presence or Absence of Visual Loss Due to Amblyopia or Structural Eye Pathology

Table 2:

Visual Acuity and Eyelid Measurements of Pediatric Patients With Congenital Blepharoptosis Based on the Presence or Absence of Visual Loss Due to Amblyopia or Structural Eye Pathology

Correlative analysis of the initial and final visual acuity (logMAR) for pediatric patients diagnosed as having congenital blepharoptosis according to the presence of amblyopia and organic eye pathology. Bold circles indicate the presence of more than one data point at a designated level. r = correlation coefficient rho; P = statistically significant; logMAR = logarithm of the minimum angle of resolution

Figure 1.

Correlative analysis of the initial and final visual acuity (logMAR) for pediatric patients diagnosed as having congenital blepharoptosis according to the presence of amblyopia and organic eye pathology. Bold circles indicate the presence of more than one data point at a designated level. r = correlation coefficient rho; P = statistically significant; logMAR = logarithm of the minimum angle of resolution

Independent risk factors associated with final visual acuity were presence of amblyopia (correlation coefficient [ß] ± standard error [SE] = −0.29 ± 0.04; P < .001), anisometropia (ß ± SE = −0.27 ± 0.06; P < .001), and ptosis severity (ß ± SE = −0.09 ± 0.04; P = .012). Initial visual acuity, visual acuity at first postoperative examination, MRD1 at diagnosis, and MRD1 at first postoperative examination were found to be associated with final visual acuity (Table 3). There was no significant difference in final visual acuity between unilateral and bilateral ptosis (P = .342).

Relationship Between Clinical Parameters and Final Visual Acuity in Patients With Congenital Blepharoptosis as Evaluated With Stepwise Regression Analysis

Table 3:

Relationship Between Clinical Parameters and Final Visual Acuity in Patients With Congenital Blepharoptosis as Evaluated With Stepwise Regression Analysis

Anisometropia was significantly higher in eyes with amblyopia than eyes without amblyopia (36.7% vs 4.4%, respectively) (P < .001). Severe ptosis was twice as prevalent in patients with amblyopia than in patients without amblyopia (83.3% vs 40.2%, respectively) (P < .001).

Strabismus was documented in 11 of 123 patients (8.9%): 2 had esotropia, 1 had exotropia, 2 had hypotropia, 1 had hypertropia with exotropia, 1 had double elevator palsy, 1 had Möbius syndrome, 1 had Brown syndrome, 1 had congenital superior oblique palsy, and 1 had exotropia with congenital extraocular muscle fibrosis syndrome. Amblyopia was present in 27.3% of patients with strabismus.

Discussion

Congenital blepharoptosis occurs in approximately 1 of 842 births and accounts for 75% of childhood ptosis.13 The primary concern related to the abnormal eyelid contour is the potential for amblyopia and permanent visual loss.1,2,4 Previous studies have sought to identify the frequency of refractive errors, amblyopia, and strabismus associated with pediatric ptosis.1–4,6,7,14 Amblyopia is known to occur with a significantly higher frequency in congenital ptosis (15% to 30%) than seen in the general population (1% to 5%) and develops secondary to anisometropia or occlusion of the pupillary axis.2,3,7,15 A recent meta-analysis by Wang et al.2 investigated the frequency of amblyopia and strabismus in congenital blepharoptosis in 19 published studies and found the pooled prevalence rate of amblyopia to be 22.7% in this patient population. The pooled prevalence rate and rates from previously mentioned studies compare well with the current study, which reported a prevalence rate of 24.4% in a white population from a tertiary referral center.

We identified that the overwhelming majority (83.3%) of children with amblyopia had severe ptosis causing near to complete or complete obstruction of the visual axis, which is indicative of the close relationship between severe ptosis and amblyopia. This finding appears to be in agreement with Srinagesh et al., who found that amblyopia was observed more frequently in eyes with severe ptosis and was not observed in eyes with symmetric eyelid involvement.7 More than 50% of patients with amblyopia in our cohort had deprivational amblyopia. This result was substantiated in previous studies3,4 and reaffirms the presence of abnormal eyelid contour as a more frequently observed amblyogenic factor than anisometropia. In the current study, the rate of amblyopia was also similar in patients with strabismus (27.3%), closely paralleling the overall frequency of amblyopia in the entire patient cohort.

Our findings have also revealed that there is a subset of patients with congenital ptosis who have underlying structural eye problems that lead to pregeniculate visual impairment independent of amblyogenic insults. We found the prevalence of this ocular pathology to be approximately 5% in pediatric patients with congenital blepharoptosis. These structural disorders contribute to abnormal visual experiences in these patients and often lead to worse visual outcomes than those of amblyogenic origin. Because these disorders are rare in the general pediatric population,16 our findings suggest that congenital blepharoptosis increases the frequency with which anterior segment dysgenetic conditions appear in patients affected with this condition and supports the theory that it is not an isolated ocular malformation.

Our findings suggest that in the setting of congenital ptosis, visual acuity and MRD1 at initial presentation are correlated with final visual acuity. In a previous study, the presence of preoperative MRD1 of 1 mm or less, preoperative eyelid fissure of 4 mm or more, and preoperative anisometropia have been reported to be associated with amblyopia following frontalis sling surgery in patients with congenital ptosis.6 Although the results of the current study are to be expected, they support the theory that more aggressive treatment is necessary in the presence of low MRD1 and inadequate visual function at presentation, regardless of the absence of complete visual axis obstruction.

The results of the current study should be interpreted in the light of certain limitations. The study was retrospective in nature and there is a possibility that subtle organic eye pathology or amblyopia may have been overlooked. Visual acuity results were not available for all patients included in the study and visual function assessments were performed in only 92% of patients. Thus, children who presented with congenital blepharoptosis requiring surgical correction but who did not have quantifiable visual acuity results were excluded. Amblyopia may have coexisted in patients with organic pathology and may have contributed to the poor visual outcomes. The compliance rates for amblyopia treatment and whether patients actually received the recommended duration of part-time occlusion per day could not be adequately determined from their charts. Additionally, MRD1 measurements may not have been taken in the exact same manner. However, the study was conducted in a university setting that served as a tertiary center wherein an experienced oculoplastic surgeon and a dedicated pediatric ophthalmologist were involved in the care of the patients. It must be noted that the aim of this study was not to evaluate the refractive errors associated with congenital ptosis because this association has been investigated in great detail in previous studies, which uniformly demonstrated increased frequency of visually significant astigmatic refractive errors and anisometropia in eyes with a 15% to 25% prevalence rate.1–3,15

The prevalence of blepharophimosis reported in the current study (8.1%) appears higher than that reported in a population-based cohort (3.1%) involving patients younger than 19 years who were diagnosed as having congenital ptosis.13 Our results are most likely reflective of the patient population seen in a tertiary center setting. Griepentrog et al.13 also found a higher prevalence of simple congenital ptosis (84.4%), which is similar to our rate of 79.6%.

The results of the current study reveal that visual function loss was present in 28.5% and persistent visual impairment in 11% of pediatric patients with congenital blepharoptosis in our cohort. Amblyopia is frequently associated with severe eyelid ptosis, whereas deprivational amblyopia is detected in more than half of the affected children. Structural ocular pathology independently contributes to visual impairment in congenital blepharoptosis and confers a worse visual prognosis than amblyogenic insults. Patients with severe blepharoptosis and those who have poor visual function at presentation are at a higher risk for visual loss and may benefit from a more aggressive approach with earlier correction of ptosis and more frequent follow-up visits. Awareness of both amblyogenic and structural ocular pathology–related insults to the developing visual system in pediatric patients with congenital blepharoptosis will improve the level of ophthalmic care and final visual outcomes in this patient population.

References

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Comparison of Visual Acuity and Eyelid Measurements in Pediatric Patients With Refractive Versus Deprivational Amblyopia in the Setting of Congenital Blepharoptosis

ParameterRefractive Amblyopia (n = 9)Deprivational Amblyopia (n = 25)Pa
Visual acuity at diagnosis (logMAR)0.24 ± 0.070.52 ± 0.29< .001b
Final visual acuity (logMAR)0.16 ± 0.160.32 ± 0.27.130
Initial MRD1 (mm)0.67 ± 1.11−0.72 ± 1.06< .001b
Final MRD1 (mm)2.89 ± 0.332.52 ± 0.71.188
Age at surgery (years)11.8 ± 6.528.58 ± 5.12.094

Visual Acuity and Eyelid Measurements of Pediatric Patients With Congenital Blepharoptosis Based on the Presence or Absence of Visual Loss Due to Amblyopia or Structural Eye Pathology

ParameterNon-Amblyopic Eyes (n = 100)Amblyopic Eyes (n = 36)Eyes With Structural Eye Pathology (n = 7)
Visual acuity at diagnosis (logMAR)0.01 ± 0.030.43 ± 0.280.53 ± 0.45
Final visual acuity (logMAR)0.01 ± 0.030.29 ± 0.280.55 ± 0.42
Initial MRD1 (mm)0.4 ± 1.2−0.33 ± 1.20.6 ± 0.5
Final MRD1 (mm)2.8 ± 0.52.6 ± 0.62.7 ± 0.8
Age at surgery (years)10.1 ± 5.49.3 ± 5.411.1 ± 7.2

Relationship Between Clinical Parameters and Final Visual Acuity in Patients With Congenital Blepharoptosis as Evaluated With Stepwise Regression Analysis

ParameterrP
Age at diagnosis (months)−0.011.902
Visual acuity at diagnosis (logMAR)0.842< .001a
Visual acuity at immediate postoperative examination (logMAR)0.959< .001a
MRD1 at diagnosis (mm)0.233.018a
MRD1 at first postoperative examination (mm)0.214.032a
MRD1 at final examination (mm)0.112.219
Age at surgery (years)−0.046.616
Authors

From the Department of Ophthalmology, Iskenderun State Hospital, Iskenderun/Hatay, Turkey (OU); the Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois (MCM); and the Department of Ophthalmology, Hacettepe University, Ankara, Turkey (UE).

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank Hakan Cakir for conducting the statistical analysis of the study.

Correspondence: Mehmet C. Mocan, MD, Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL 60612. E-mail: cmocan@uic.edu

Received: September 09, 2019
Accepted: December 30, 2019

10.3928/01913913-20200120-01

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