To present an unusual complication following extensive levator muscle resection surgery.

A 13 year-old boy was referred to our oculoplastic clinic because of left eyelid ptosis from early childhood. The patient underwent left levator muscle resection surgery (supramaximal levator resection) through upper eyelid crease skin incision. First day post-operative external ocular examination showed limitation of all gazes in both eyes; both eyes were fixed in relative downgaze position. Six days after surgery, external ocular examination showed normal extraocular motility in both eyes without any limitation in movements.

Post-operative ophthalmoplegia, specially following orbital surgery, should prompt the surgeon to search for sight threatening complications. These complications include retrobulbar haemorrhage and other compartment syndromes that involve orbit, orbital apex syndrome, damage to extraocular muscle or their nerves and limitation of movement due to tissue manipulation during surgery. After excluding these important causes of ophthalmoplegia, the differential diagnosis could be limited to: limitation of upgaze due to maximal levator resection (discussed later in this part), avoidance of voluntary ocular movements due to post-surgical pain and edema, malingering or other non-organic causes. In this case, ophthalmoplegia was temporary, reversible and imaging studies were within normal limits so we concluded that the most probable diagnosis was non-organic disease. Another possible mechanism is post-operative edema and hyperemia after extensive levator muscle surgery that causes motility restriction.

This case and other similar case reports can assist us for managing post-operative ophthalmoplegia due to maximal or multiple levator muscle surgeries. After ruling out sight-threatening conditions, we should note that this complication may be subsided with improvement of post-surgical edema and may not need extensive systemic evaluations.