Superior Corneal Perforation Following Ptosis Surgery: A Rare Case Of Exposure Keratopathy

To report a rare case of exposure-related superior corneal perforation following ptosis surgery, resulting from severe upper eyelid retraction and an associated monocular elevation deficit with hypotropia, compounded by an absent Bell’s phenomenon.

This case was managed at Ibn Al-Haitham Teaching Eye Hospital, a tertiary ophthalmology referral center in Baghdad, Iraq, by a team of corneal and oculoplastic surgeons.

This report presents a rare case of superior corneal perforation in a young child three years after ptosis surgery. Unlike typical exposure keratopathy affecting the inferior cornea, this case involved the superior one-third due to severe post-surgical upper eyelid retraction. The patient had monocular elevation deficit and absent Bell’s phenomenon, leading to chronic exposure of the superior cornea.

The child had previously undergone two surgeries to address Marcus Gunn jaw-winking phenomenon, though clear records were unavailable. This was followed by an internal fixation procedure, most likely a Whitnall sling, without addressing the associated hypotropic strabismus misalignment.

Management involved tectonic keratoplasty to restore corneal integrity, upper eyelid blepharotomy to correct lid retraction, and tarsorrhaphy to prevent further exposure. Postoperative recovery was uneventful, with significant improvement in ocular surface stability.

This case highlights the importance of preoperative assessment of eyelid mechanics in ptosis surgery, especially in patients with monocular elevation deficit. It emphasizes the need for a tailored surgical approach to prevent unusual exposure-related complications.

This case highlights the importance of thorough preoperative evaluation in ptosis surgery, particularly in patients with compromised ocular protection. Simple complaints like jaw-winking ptosis can lead to severe complications like corneal perforation if not properly managed. Surgical correction should start with strabismus realignment, followed by levator aponeurotic disinsertion and extirpation. Frontalis suspension should use reversible materials like silicone or Prolene, avoiding irreversible options like frontalis or Whitnall sling. A tailored approach is crucial to prevent exposure-related risks and vision-threatening outcomes.