Orbital Asymmetry in Congenital Ptosis

We report orbital asymmetries associated with congenital ptosis. This was a prospective, observational study enrolling all cases of idiopathic, nonsyndromic congenital ptosis presenting to a tertiary university center between 2023 and 2025. Exophthalmometry was performed using both Hertel and Naugle devices by 2 independent observers. Average intereye differences were calculated. Axial length was measured using optical biometry. Any other nonsyndromic eyelid or periocular findings were noted. N=26 patients were enrolled. Average age was 8.8±8.5 years (range 7 mo-26 y). Exophthalmometry consistently demonstrated relative enophthalmos on the more ptotic side (n=25, 96%), with an average enophthalmos of -1.21±0.47 mm (P<0.001) using the Naugle exophthalmometer, and -1.29±0.49 mm (P<0.001) using the Hertel. There was no difference in axial globe length between ptotic and nonptotic eyes (0.02±0.48 mm, P=0.86). Relative enophthalmos on the ptotic side was independent of differences in axial length (R2=-0.02, P=0.44), age (R2=-0.01, P=0.40), or ptosis severity as judged by levator function (R2=0.02, P=0.20) by multiple linear regression. Associated orbitofacial conditions were observed in 15 patients (58%), and all occurred on the ptotic side. These included NLDO (n=6, 23%), dermoid cyst (n=3, 12%), septal deviation (n=3, 12%), and Marcus-Gunn jaw wink (n=3, 12%). In conclusion, congenital ptosis was reliably associated with relative enophthalmos independent of globe size or ptosis severity, and a high incidence of other oculofacial conditions. These findings complement facial asymmetries previously reported in association with congenital ptosis.