Nocturnal lagophthalmos after levator surgery: clinical correlates and risk factors

To investigate nocturnal lagophthalmos after levator surgery for simple congenital ptosis, focusing on its correlation with office-based (clinical) lagophthalmos and factors contributing to clinical-nocturnal discrepancy.

A retrospective review was conducted on 109 children (median age, 7 years) who underwent unilateral levator surgery between 2021 and 2024. Lagophthalmos was evaluated clinically in the office and nocturnally using photographs obtained during sleep. Bell's phenomenon was assessed during daytime examination by observing upward and outward globe rotation on attempted eye closure, and nocturnal photographs were reviewed for globe position. Margin reflex distance 1 (MRD1), levator function (LF), and corneal fluorescein staining were recorded. Associations with demographic variables, ptosis severity, surgical type, and exposure keratopathy were analyzed.

Sixty-five percent of patients underwent levator resection and 34.9% levator plication. At a median follow-up of 20 months (range, 5.1-58), median clinical lagophthalmos was 0 mm (range, 0-2.9) compared with 3.1 mm nocturnally (range, 0-8.3) (p < 0.001). Preoperatively, Bell's phenomenon was good in 99.1% of eyelids and remained good in 85.3% postoperatively. Nocturnal evaluation revealed scleral show in 13.8%, corneal show in 36.7%, and pupillary show in 22.9%. No significant associations were found between lagophthalmos change and demographics, ptosis severity, surgical type, MRD1, LF, or follow-up duration (p > 0.05). Greater changes were correlated with corneal staining (p < 0.001) and symptom severity (p < 0.001).

Significant nocturnal lagophthalmos with corneal exposure is common after levator surgery for congenital ptosis despite near-complete eyelid closure on clinical assessment. No visually threatening corneal complications were observed.