Clinical Outcomes of Surgery for Double Elevator Palsy

To evaluate the clinical findings and surgical management of patients with congenital unilateral double elevator palsy (DEP) or monocular elevation deficiency (MED) In a non-comparative interventional case series, 27 consecutive cases of DEP were studied. Hypotropia, elevation deficiency, and pseudoptosis were corrected by Knapp or Callahan procedure with or without inferior rectus recess. Ptosis was corrected by anterior levator resection (ALR) and brow suspension. Levator excision and brow suspension was performed for correction of accompanying jaw winking ptosis. Horizontal strabismus repair, blepharoplasty, and double Z-plasty for epicanthal folds were done in some cases. This series included 15 female and 12 male subjects with mean age of 13±10 years. All patients except two were sporadic cases. Definite congenital DEP was present in two members of a consanguineous family. In most cases, the presenting complaint was ipsilateral ptosis (74%). Hypotropia with various degrees of severity was found in 20 cases (74%). Six patients (22%) had jaw winking ptosis of the ipsilateral eye. Knapp procedure was performed in 6 and Callahan procedure was performed in 4 cases. True ptosis was corrected by anterior levator resection in 9 and brow suspension in 8 eyes. Levator excision and brow suspension was performed in 3 patients with accompanying jaw winking ptosis. In one case with mild jaw winking, levator resection was done. Hypotropia was corrected in 80% after surgery and eye elevation increased by 2515 PD. Ptosis correction procedures succesfully improved chin up position and cosmetic appearance in addition to opening the visual axis. Anterior segment ischemia was not found in any cases after one year of follow up. Blepharoptosis and hypotropia are the chief clinical features and presenting complaints in this condition. Knapp and Callahan procedure with or without inferior rectus recess are effective and should be consider prior to considering surgical intervention for the ptosis.