congenital ptosis is an abnormally low position of the upper eyelid in relation to the globe , which occurs either at birth or soon after . there are several methods of ptosis surgery , including levator muscle resection , frontalis suspension procedure , fasanella - servat procedure , and mller muscle conjunctival resection.1,2 one of the most popular methods of ptosis surgery is the frontalis suspension procedure . there are various materials available to secure the lids to the frontalis muscles in the frontalis suspension procedure , including polypropylene suture , nylon suture , silicone , mersilene mesh , and gore - tex material.3 we are reporting a rare case of infected gore - tex material that was used in modified frontalis sling surgery for congenital ptosis . a 7-year - old chinese boy with no known medical history , presented with history of right eye ptosis since he was 10 months old . he had a marginal reflex distance of 1 mm , with levator function of 3 mm in the right eye . the marginal reflex distance of the left eye was 2 mm , with 7 mm levator function . he underwent ptosis surgery on the right eye as he developed mild amblyopia in the right eye , with the best - corrected vision of 6/12 . a right eye frontalis sling procedure with modified fox s pentagon method4 chloramphenicol ointment was applied 8-hourly to the surgical wound site on the right upper eyelid . the patient was discharged on day 1 postoperation , with plan to review after 1 week . however , he defaulted his follow - up and only came back 1 month after surgery . he had used his medication for only 1 week and had stopped thereafter . at this presentation , he complained of painful swelling ( of 7 days duration ) of the right upper eyelid . the right upper eyelid swelling was associated with pus discharge from the surgical wound site . his best - corrected visual acuity was 6/12 in the right eye and 6/9 in the left eye . there was presence of crusted pus at the surgical wound site ( figure 1 ) . a diagnosis of right eye preseptal abscess secondary to the infected surgical wound was made . the patient was admitted and treated with intravenous co - amoxiclav 800 mg ( 25 mg / kg ) 8-hourly for a duration of 1 week . chloramphenicol ointment was applied 8-hourly to the infected surgical wounds , together with instillation of topical chloramphenicol eye drops 6-hourly to the right eye . an emergency incision and drainage of the right upper eyelid was performed , and about 5 ml of pus was drained out . post - incision and drainage , the right upper eyelid was still inflamed and swollen with partial mechanical ptosis ( figure 2 ) . in view of no improvement in the healing process , the antibiotic was changed to intravenous cefotaxime 750 mg ( 25 mg / kg ) 8-hourly for a duration of 1 week . the topical antibiotic eye drop was also changed to topical moxifloxacin 6-hourly for the right eye . however , there was still no improvement ; hence an antibiotic combination of intravenous ceftazidime 750 mg ( 25 mg / kg ) 8-hourly for 5 days and intravenous amikacin 210 mg ( 15 mg / kg ) 12-hourly for 3 days was commenced . a third incision and drainage was performed together with removal of the gore - tex material . a culture from the final pus sample isolated multidrug - resistant acinetobacter species , which was resistant to all penicillins , cephalosporins , carbapenems , fluoroquinolones , and aminoglycosides there was resolution of the right upper eyelid swelling , with no more pus discharge . the patient was discharged , with chloramphenicol ointment to apply to the surgical wound 8-hourly for 2 weeks . after 6 months follow - up ( about 3 months post - removal of gore - tex material ) , the patient s right upper eyelid was healed with scarring , but without ptosis ( figure 3 ) . frontalis suspension surgery is a commonly used surgery in cases of congenital ptosis with poor levator function , chronic progressive ophthalmoplegia ( cpeo ) , muscular dystrophy , third nerve palsy , myasthenia gravis , and aponeurotic ptosis in elderly patients.1,3 there are several suspension materials that can be used in frontalis suspension surgery . synthetic materials such as polypropylene suture , nylon suture , silicone , mersilene mesh , and gore - tex can also be used.5 gore - tex material or expanded polytetrafluoroethylene ( eptfe ) is suitable for suspension surgery because it is less bulky and less stretchable.5 it is a nontoxic polymer used in various other implantable medical products , including vascular grafts and hernia repair patches . unlike other implantable materials , eptfe is biocompatible . micropores within the material are too small to allow infiltration of fibrovascular tissues hence allowing for easier removal or manipulation to adjust the eyelid height.6,7 however , its porous nature may allow proliferation of bacterial contaminants and cause abscess formation , resulting in a high risk of soft tissue complications . in our patient , constant scratching may have led to infection of the wound . with tracking of the long , porous eptfe material through an open wound the periorbital abscess was chronic and persistent even after treatment with multiple antibiotics and repeated incision and drainage , indicating the highly virulent nature of the causative organism . this could be due to the formation of biofilm by the causative bacteria , especially on biomedical implants , causing antimicrobial resistance.8 complete resolution in our case occurred only after removal of the gore - tex material , which might have harbored the virulent microorganism . there were a few other reports of complications of ptosis surgery such as granuloma and infection.2,3,9 in a retrospective study of 59 frontalis suspension procedures , infection with preseptal cellulitis appeared in one case ( 1.7% ) and required removal of the material , and in two cases ( 3.4% ) there were foreign body granulomas that were resolved by excision.10 there were other reports of post - ptosis surgery complicated by long - standing postoperative infection which were mostly associated with mycobacterium or candida infection.11,12 however , to our knowledge , there was no reported case of long - standing post - ptosis surgery infection involving multidrug - resistant acinetobacter species . acinetobacter rarely colonizes implant materials;13 it commonly causes nosocomial infections such as pneumonia , urinary tract infection , and skin infections.14,15 in a delayed and long - standing post - frontalis surgery infection , multidrug - resistant organisms may be responsible for delayed healing and poor response to treatment . surgical removal of infected slings and a prolonged course of antibiotics may be required for complete resolution .
a 7-year - old boy had a case of congenital ptosis of the right eye and has undergone frontalis sling surgery using gore - tex material . 
 there was no intraoperative or immediate postoperative complication . 
 however , the patient defaulted his follow - up and presented with right eye preseptal abscess secondary to infected surgical wound 1 month after surgery . 
 he was treated with multiple antibiotics and underwent repeated incision and drainage procedures . 
 however , there was still no resolution of the right eye preseptal abscess . 
 the patient s condition subsequently improved after removal of the gore - tex material and treatment with an antibiotic combination of ceftazidime and amikacin . 
 microbiological analysis finally isolated the multidrug resistant acinetobacter species . at 6 months 
 follow - up , his right upper eyelid was healed with scarring , but without ptosis .