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Background/AimRecent studies have demonstrated adverse psychosocial and mental health disorders among children with ocular disorders. The mental health burden of children with simple congenital ptosis, however, is unknown. The purpose of this study was to compare the psychosocial and mental health findings of children with simple congenital ptosis with controls.MethodsThe medical records of all children (<19 years) diagnosed with simple congenital ptosis from 1 January 1965 through 31 December 2004 while residing in Olmsted County, Minnesota were retrospectively reviewed for psychosocial and mental health morbidity. One-to-one randomly selected age-matched and gender-matched controls from the same population were similarly reviewed.Results81 children with ptosis were diagnosed at a mean age of 3.2 years (range, 1 month–16 years), 35 (43.2%) of whom were girls. An adverse psychosocial development was diagnosed in 41 (50.6%) patients with simple congenital ptosis monitored to a mean age of 21.4 years, compared with 26 (32.5%) controls (p=0.02). A mental illness was diagnosed in 31 (38.3%) patients with ptosis compared with 16 (20%) controls (p=0.01). Children with ptosis were 2.5 times more likely than controls to develop a mental illness and 2.1 times more likely to develop a psychosocial maladjustment. Patients with ptosis were also significantly more likely to have more mental health disorders (p=0.02) and a longer duration of psychotropic medication use (p=0.005).ConclusionsChildren diagnosed with simple congenital ptosis in this population had significantly greater psychosocial and mental health morbidity compared with controls. Children with ptosis may benefit from early psychosocial intervention.

BackgroundBoth external levator resection (ELR) and Müller’s muscle-conjunctival resection (MMCR) are procedures well known to improve marginal reflex distance (MRD1) in patients with ptosis. This study aims to understand differential post-operative changes in eyelid contour for MMCR and ELR surgery.MethodsIn this cross-sectional cohort study, patients affected by involutional ptosis were randomized into two groups: those who underwent ELR or MMCR surgery. Pre-operative and late post-operative photographs were obtained. Digital analysis of the lid contour was performed by measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. Mean distance at each position was compared pre- and post-operatively between the groups.ResultsThe final sample included 60 eyes from 39 patients, 30 eyes per group. At each time point there was significant variation in height across the eyelid (p < 0.05). A significant (p < 0.05) group difference in vertical height was noted only at the 2 and 4 mm temporal positions in the post-operative analysis, with the ELR group being slightly higher. There were no significant differences in MRD1, pre- or post-operatively, between the ELR and MMCR groups.ConclusionsBoth ELR and MMCR are effective at elevating the eyelid in multiple positions across the length of the eyelid. Although they do not produce significantly different MRD1 results, ELR was associated with a greater eyelid height at the 2 and 4 mm temporal positions.

Anecdotal reports have recently circulated suggesting that intramuscular injection of bacteriostatic saline (BS)—which contains benzyl alcohol (BnOH)—can reverse botulinum toxin type A (BoNTA)-induced brow ptosis. Given the well-established intracellular persistence of BoNTA’s light chain and its irreversible cleavage of SNAP-25, such rapid functional recovery challenges existing pharmacological understanding. This study employed high-resolution pharmacokinetic/pharmacodynamic (PK/PD) modelling using the AesthetiSim™ platform to systematically evaluate this hypothesis. A total of 30,000 virtual patients were randomized to receive BoNTA alone, BoNTA followed by BS injection, or BoNTA followed by normal saline (NS) at Day 7. The model incorporated BoNTA diffusion, internalization, SNAP-25 cleavage, neuromuscular output, and transient BS effects on membrane permeability and endosomal trafficking. Simulated recovery trajectories were tracked over 90 days. The primary outcome, time to 80% restoration of baseline frontalis muscle force (T80), averaged 42.0 days in the BoNTA-only group and 35.5 days in the BS group (Δ = −6.5 days; p < 0.001). Only 13.9% of BS-treated patients reached the T80 threshold by Day 30. Partial reactivation (T30) occurred earlier with BS (21.8 ± 5.3 days vs. 27.3 ± 4.9 days), and the area under the effect curve (AUEC) was increased by 9.7%, reflecting higher overall muscle function over time. In molecular simulations, BnOH produced a minor rightward shift in the BoNTA–SNAP-25 dissociation curve, but receptor occupancy remained above 90% at therapeutic toxin concentrations, suggesting no meaningful impairment of binding affinity. A global Sobol sensitivity analysis demonstrated that the primary driver of recovery kinetics was intracellular LC degradation (49% of T80 variance), while BS-modulated extracellular parameters collectively contributed less than 20%. These findings indicate that BS does not reverse the molecular action of BoNTA but may transiently influence recovery kinetics via non-receptor-mediated pathways such as increased membrane permeability or altered vesicular trafficking. The magnitude and variability of this effect do not support the notion of a true pharmacologic reversal. Instead, these results emphasize the need for mechanistic scrutiny when evaluating rapid-reversal claims, particularly those propagated through anecdotal or social media channels without supporting biological plausibility.

Purpose Severe congenital ptosis is commonly associated with poor levator function. This study compares the functional and cosmetic outcomes of open versus closed frontalis sling using Gore-Tex in the treatment of such conditions. Methods Randomized interventional comparative case series of 20 eyes of 13 patients with severe congenital ptosis with levator excursion < 4 mm. Patients were treated by frontalis suspension using Gore-Tex string sutures either through a skin crease incision (group 1) or supraciliary incisions (group II). Results Mean age was 5.10 ± 3.10 years in group I and 7.30 ± 4.47 years in group II. Ptosis was unilateral in six patients and bilateral in seven patients. Following surgery, there was a statistically significant improvement in the palpebral fissure width (PFW) and marginal reflex distance (MRD) in both groups (p value 0.001) with better functional outcome in group II (closed approach). The cosmetic results were better in group I (open approach). The mean operative time in group II was 18.1 ± 2.4 min, which was significantly shorter than group I (30.2 ± 3.1 min). No recurrence or grave complications were encountered during follow-up. Conclusion Gore-Tex is a useful sling material for correction of severe congenital ptosis due to poor frontalis action. Open transcrease approach is recommended in absence of lid crease whereas closed approach is better used in cases with preserved crease due to its superior functional outcome

Objective To evaluate the efficacy and safety of peribulbar triamcinolone acetonide injection for treating ocular myasthenia gravis (OMG), with a comparison of traditional oral drug therapy. Methods A total of 22 patients with OMG who received periocular triamcinolone acetonide injection (initially 20 mg weekly, then once per month later if symptoms were improved) from July 2019 to July 2022 were evaluated by a comparison of symptom degree before and after treatment. Adverse reactions were also monitored during the period of treatment. The period of follow-up was more than 6 months. Additionally, a comparison of the treatment efficacy between this periocular injection and traditional oral administration was performed in OMG patients. Results After 4 weeks of treatment, the degree of ptosis in OMG patients decreased to -3.00 ± 0.69, compared to the value (-0.86 ± 1.32) before treatment. The degree of ophthalmoplegia also decreased from 3.12 ± 0.72 to 0.86 ± 0.88 ( P  < 0.001) after treatment. The achievement rates of minimal manifestations status (MMS)for ptosis and ophthalmoplegia after 4 week-treatment were 86.3% and 75%, respectively, while they were 50% and 30% in patients with traditional oral administration. There was statistically significant difference only in MMS (rather than symptom relief rate and generalization conversion rate) between two groups. No serious complications (except for intraorbital hematoma) were found in OMG patients during the treatment period. Conclusion Repeated peribulbar injection of triamcinolone acetonide can effectively alleviate the initial symptoms of OMG patients. However, the evaluation of its long-term efficacy is still needed. Clinical Trial Registry This study has been clinically registered by Chinese Clinical Trial Registry (ChiCTR), first trial registration date:05/07/2019, registration number: ChiCTR1900024285.

To present cases of ptosis in HIV-1 patients on long-term antiretroviral therapy (ART) and review the existing literature. Five HIV-1-positive patients with slowly progressive bilateral ptosis underwent a comprehensive diagnostic evaluation, including imaging studies, neurophysiological testing, muscle biopsy, and genetic analysis. A literature review was conducted. On clinical examination, all patients presented with bilateral symmetrical non-fatigable ptosis, three exhibited facial lipoatrophy and two also had mild multidirectional ophthalmoparesis and all had ocular abnormalities in Hess screen test. Additionally, one patient displayed proptosis, three had floppy lower eyelids, and four presented with exotropia. Anti-acetylcholine receptor antibodies were negative in all patients. Brain magnetic resonance imaging (MRI), motor unit potential analysis, and single-fiber electromyography were unremarkable. Orbital MRI revealed introrbital fat expansion in one patient, and limb muscle biopsies were inconclusive in two cases. Blood genetic testing for chronic progressive external ophthalmoplegia was negative in all patients. A total of 30 similar cases have been documented in the literature, with some studies reporting key findings such as muscle histology indicative of mitochondrial myopathy, MRI revealing patchy extraocular muscle hyperintensity, and muscle genetic testing identifying mitochondrial deoxyribonucleic acid (DNA) deletions. Ptosis surgical repair appears to be the most effective treatment. HIV patients on long-term ART may develop ocular muscle involvement due to mitochondrial dysfunction, with bilateral ptosis being the primary manifestation. Diagnosis is challenging and requires the exclusion of other conditions. Ptosis surgery can significantly improve quality of life. •HIV patients under long-term ART may develop muscle ocular abnormalities.•The main symptom is insidious bilateral ptosis.•Diagnosis of this entity is challenging, and mimics must be excluded.•Blood workup, imaging, EMG and muscle biopsy may be required for diagnosis.•Ptosis surgical correction has been shown to improve quality of life.

To evaluate the prevalence of ptosis, strabismus and the combination of both after glaucoma surgery and determine which kind of surgery is most likely to be linked to these complications. A total of 705 clinical records of patients who underwent glaucoma surgery at the University Eye Clinic of IRCCS Ospedale Policlinico San Martino, Genoa, from January 1, 2010, to December 31, 2020, were retrospectively evaluated. Surgery procedures were divided in three groups: \"Ab interno\", \"Ab externo\" and \"Muscle isolation\". Out of all patients 26 developed ptosis alone (3.7%), two developed bilateral ptosis, with a mean of 2.2 ± 1.08 procedures per patient. Highest incidence of ptosis was noticed in patients who underwent muscle isolation surgery (5.7%). Twelve patients developed strabismus alone (1,7%), four underwent unilateral surgery and eight bilateral surgery, with an average of 3.3 ± 1.78 procedures per patient. Strabismus was more frequent following extraocular muscle manipulation surgery (7.5%), showing a statistically significant difference (OR: 6.57; 95% CI: 1.71-21.65; p = 0.003) Seven patients developed both strabismus and ptosis (1.0%), one patient with bilateral ptosis. Four underwent bilateral surgery and three underwent unilateral surgery. The mean number of surgeries was 2.9 ± 1.07, showing a statistically significant difference compared to the uncomplicated glaucoma group (OR: 1.58; 95% CI: 1.01-2.25; p = 0.02). The prevalence of both ptosis and strabismus was higher after muscle isolation surgery (1.9%). Ptosis, strabismus and the combination of both are rare complications after glaucoma surgery, mostly linked to surgery with muscle isolation.

Vincristine, a chemotherapy drug primarily used in pediatric cancer treatments like acute lymphoblastic leukemia and Wilms’ tumor, is known for neurotoxic side effects, including a rare but under-discussed manifestation—vincristine-induced ptosis. This systematic review (PROSPERO: CRD42024617946) analyzed data from three databases, identifying 379 articles. Of these, 28 articles encompassing 31 unique pediatric cases were included, with Turkey contributing the highest number of cases (9 cases, 29.03%). The median age was 3 years (IQR: 2 – 5.5), with 58.06% male (18 cases) and 41.93% female (13 cases). Ptosis appeared bilaterally in 61.29% (19 cases) and unilaterally in 38.71% (12 cases), showing a left-side predominance in unilateral cases. The median time to symptom onset after the last vincristine dose was 6 days (IQR: 2 – 12). Treatment protocols varied; 74.19% (23 cases) adjusted or discontinued vincristine, with 34.78% (8 cases) restarting after skipping doses. Pyridoxine with or without pyridostigmine was used in 70% (14 of 20 treated cases), and recovery was generally favorable, with symptoms resolving within 28 days (IQR: 22.75 – 42) in most cases. Mild residual ptosis was noted in 9.67% (3 cases). Our review shows the significant variability inherent to management approaches in this patient demographic and highlights the need for standardized documentation and treatment approaches, proposing “VINTOSIS-3 ” as a practical treatment protocol. Furthermore, the VICTORIA (Vincristine-InduCed pTOsis cRIteriA) Grading is introduced to standardize ptosis severity evaluation. We further emphasize the importance of early detection, vigilant monitoring, and tailored interventions to balance neurotoxicity management with chemotherapy efficacy. What is Known: • Vincristine, a widely used chemotherapeutic agent in pediatric oncology, is associated with toxic side effects, primarily peripheral neuropathy. • Ocular complications of vincristine, including ptosis, have been reported but remain under-recognized. What is New: • Vincristine-induced ptosis is predominantly bilateral, but when unilateral, it shows a left-sided predominance and typically appears after a median of four doses. • The proposed VICTORIA Grading standardizes severity assessment, and the VINTOSIS-3 protocol provides a structured approach to management.

Background Systemic lupus erythematosus (SLE) is an autoimmune disease with diverse manifestations, including rare neuro-ophthalmic complications. Isolated unilateral ptosis as a presenting sign of SLE is uncommon and diagnostic uncertainty often exists. Case presentation A 30-year-old woman with a 16-year history of SLE presented with acute right-sided ptosis without other neurological deficits while on stable maintenance immunosuppressive therapy. MRI of the brain and orbits, along with other relevant investigations, excluded common structural causes and showed no abnormalities. Serological testing indicated moderately active SLE, supporting an autoimmune flare as the likely mechanism. Myasthenia gravis–specific testing was not performed, a recognized limitation, but was considered clinically unnecessary given the absence of fatigability, diurnal variation, or generalized weakness. The ptosis resolved completely within 24 h of initiating high-dose systemic corticosteroid therapy. Conclusions Isolated unilateral ptosis may represent a rare neuro-ophthalmic manifestation of SLE, though alternative diagnoses cannot be definitively excluded. The rapid steroid response may suggest an inflammatory or autoimmune mechanism, underscoring the importance of considering such etiologies and initiating timely immunosuppressive therapy when appropriate.

Background We examined the effect of surgical repair on the pattern of refractive errors in Korean patients with congenital blepharoptosis. Methods We reviewed the clinical records of 54 patients with congenital blepharoptosis who attended our hospital from 2006 to 2012 and underwent a detailed refractive examination before and after ptosis repair surgery. Among them, 21 of the patients whose refractive data was available for both before and after the surgery were included in order to observe the effect of ptosis repair surgery on refractive error characteristics. The astigmatism groups were divided into three subgroups: with-the-rule (WTR), against-the-rule (ATR), and oblique astigmatism (OA). We also evaluated the severity of astigmatism. Results Before surgery, the ptotic eyes had more severe astigmatism and a greater percentage of OA than the fellow eyes. The changes in astigmatism magnitude before and after surgery were not significant, but the proportion of subjects with OA increased significantly. In ptotic eyes, amblyopia was found in 14 eyes (20.9 %). 3 eyes (4.5 %) were from solely occlusive visual stimulus deprivation due to severe ptosis, and 11 eyes were from refractive errors. Among refractive errors, amblyogenic astigmatism made up to the largest proportion of patients (8 patients, 11.9 %). Conclusions Ptotic eyes had more severe astigmatism and more OA than fellow eyes. Amblyogenic astigmatism was more common in ptotic eyes. A change in astigmatism toward the OA axis was significantly detected after surgery, and that can be possible amblyogenic cause. Therefore, the correction of astigmatism before and after ptosis repair surgery is very important to prevent amblyopia.