Alternative surgical methods for ptosis in patients with 18p deletion syndrome.

Dear editor

We read the article by Xu et al1 entitled “A case of 18p deletion syndrome after blepharoplasty” with great interest. In their case report, they reported a child with 18p deletion syndrome who underwent blepharoplasty for ptosis associated with the syndrome.1 The authors should be congratulated for introducing a method of cosmetic improvement for patients with this condition.

Blepharoplasty would have been enough for the right eye of the child as the width of her palpebral fissure was 7–8 mm preoperatively. However, considering that the width of her palpebral fissure was 2–3 mm in the left eye when raising her eyebrows, we would like to point out that alternative methods, such as frontalis suspension, would have been necessary for functional as well as cosmetic improvement. Frontalis suspension is the most commonly performed technique,2 especially for the patients with unilateral congenital ptosis with poor levator function less than 4 mm.3 Satisfactory outcome (from 80 to 90%) of such patients was reported when frontalis suspension was performed for severe unilateral ptosis, although the results could be less satisfactory in patients with unreliable brow function.2,3

In cases with poor forehead elevation, maximal levator resection has been introduced to be an effective alternative.3 After the maximal levator resection, significant improvement in levator function was reported.3 In addition, maximal levator resection can be cosmetically superior to frontalis suspension, as the technique can preserve natural eyelid contour and dynamic blink and does not need eyebrow elevation for eye opening.3

Finally, we would like to comment that the patient might need further evaluation, and if needed, further treatment for amblyopia of the left eye, as the patient had significantly smaller palpebral fissure in the left eye than in the right eye preoperatively. As the child is five and half years old, amblyopia treatment such as occlusion or atropine therapy might improve her vision in the left eye.