PURPOSE: To review the literature on the outcomes of severe congenital ptosis repair in the pediatric population and to assess the rates of exposure keratopathy and other complications. METHODS: A literature search was last conducted in May 2025 in the PubMed database. Articles were limited to original research in the English language that included detailed postoperative data on at least 25 eyelids with severe congenital ptosis (defined as levator function of 4 mm or less) after any given ptosis repair technique with at least 6 months of postoperative follow-up. The initial search identified 209 citations; 30 articles were reviewed in full text, and 11 articles were selected for inclusion in this assessment. The panel methodologist assigned a level of evidence rating to each of the included studies. RESULTS: One study was rated level I, 1 study was rated level II, and 9 studies were rated level III. The included studies examined frontalis flap, frontalis suspension, and maximal levator resection surgeries. They focused on a wide range of pediatric ages (infancy to 16 years), but the average age range in all cases was squarely in the younger pediatric demographic (ages 1-8 years). The literature demonstrated variable descriptions of success, revision surgery, and exposure keratopathy. Significant overlap in success, exposure, and revision exists for all 3 surgical techniques. Perhaps biased by the greater number of articles defining success, frontalis suspension surgery studies demonstrated the widest range of efficacy and had the additional surgery-specific complications of sling infections, extrusions, and granulomas. CONCLUSIONS: Although the level of evidence and dearth of comparative literature precluded evaluation of clear equivalency data, frontalis flaps, frontalis suspension, and maximal levator resection appear to have overlapping rates of success and rates of exposure. Risks of surgery may influence surgical choice. Frontalis-related techniques were associated with unique risks, including sling-specific inflammation, infection, and exposure; and flap-related lid displacement with supraduction. Long-term, multi-institutional, comparative prospective studies would allow further insight into surgical durability and complication rates. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.
Glass et al. (Thu,) studied this question.