Droopy Lids? The Bleph Boom

“The Bleph Boom: Are We Obsessed with Eyelids?” At the 2026 annual Future Beauty and Health Show at the Royal Dublin Society, the seats were full, with standing room only for those attending the bleph talk. Three oculoplastic surgeons practising in different sites in Ireland—Michéal O’Rourke, Nikolina Budimlija, and I—spoke in a panel chaired by the co-founder of Future Beauty, Liz Dwyer.

Who is suitable for surgery, and who should be cautious? What should a patient look for in a prospective surgeon? The discussion varied, moving from bland practicalities, including timing of surgery and recovery, to video recordings of a bilateral upper blepharoplasty surgery performed on the chair of the panel herself. A careful warning was given to the audience members that blood and real-life surgery were about to feature on the big screen. When the video played, I saw a mix of responses: some shielded their gaze with their hands in an involuntary ‘ick’ response, while others watched Michéal’s handiwork closely.

There are different sides to oculoplastics, a recently developed ophthalmology subspecialty. Oculoplastics is concerned with sight-threatening pathology, such as orbital cellulitis and orbital inflammation, and management of rare deadly infections such as invasive mucormycosis. At the Future Beauty show, the focus was on the aesthetic side of oculoplastics, whereby eyelid changes and malpositions (mainly age-related) can be managed with surgery.

Blepharoplasty is the headline procedure on the aesthetic side of oculoplastics and is one of the five most popular cosmetic surgeries in the UK, per the BBC. After bilateral upper blepharoplasty surgery, patient satisfaction rates typically exceed 90%. As with any surgery, there are risks, and dissatisfaction or regret are estimated to occur in up to 15%.

I am keen, when I see any patient who is complaining of droopy lids, to zero in on their exact complaint. Are they bothered about excess upper lid skin changing their appearance or blinkering their vision, or is the upper lid position lower than normal, i.e., ptotic?

Making a distinction is essential, as dermatochalasis and ptosis are two distinct entities that patients may not be able to distinguish between. Dermatochalasis, or excess upper lid skin, can be managed through bilateral upper blepharoplasty, a relatively straightforward procedure involving excision of excess skin. For an abnormally low upper lid, or upper lid ptosis, careful consideration needs to be given to a broad list of diagnoses prior to any surgical planning. Potential underlying conditions including vascular, neoplastic, and autoimmune disorders, among others, can present for the first time with a complaint of a droopy eyelid in the clinic. We do not want to miss a secondary ptosis due to Horner’s syndrome, Myasthenia gravis, or a third nerve palsy. We also do not want to misidentify ptosis in contralateral lid retraction or proptosis.

My approach to a patient with droopy lids is informed by my time in practice as a consultant, my time spent training in ophthalmology, and my fellowships in oculoplastics. I can remember Andy Gibson, consultant oculoplastic surgeon and military clinical director at James Cook University Hospital, Middlesbrough, UK, giving me a memorable framework for assessing ptosis. He instructed me on pertinent negatives that should be noted in the clinical exam. Specifically documenting important negatives in each ptosis exam is helpful, as the ingrained habit is protective when running a busy clinic. I think of this as broadly analogous to documenting ‘no tobacco dust’ in an acute posterior vitreous detachment.

Is there fatiguability or variability of lid position? After 60 seconds of sustained upgaze, worsening of a ptosis should raise suspicion for myasthenia. Ice-pack testing and bloods including acetylcholine receptor and muscle-specific kinase antibodies can be helpful. Are eye movements full and pupils equal?

Careful pupil inspection with room lights dimmed can enhance the subtle anisometropia of Horner’s syndrome; look for the smaller pupil on the ptotic side. Iopidine drops are useful to confirm this by inducing a reversal of the anisometropia, and the drops are usually readily available in clinic. A painful Horner’s is a reason to send a patient for an emergency CT angiogram head and neck, looking for carotid dissection.

Is levator function reduced? This helps with determining cause of ptosis, identifying a congenital ptosis or a potential third nerve palsy. Levator function is also essential to measure in surgical planning, as the technique to correct a ptosis with significantly reduced function is distinct from a routine aponeurotic ptosis repair.

A further caution: after determining that your patient has a straightforward problem like dermatochalasis with no lurking undiagnosed pathology, have a conversation about concerns and expectations before proceeding with surgery. In Australia, patients who seek cosmetic surgery must be screened for body dysmorphia—another condition not to miss.

This is the third in a series of columns discussing conditions of eyelids. Previous columns are available on the EuroTimes website.

Clare Quigley MD is a Consultant Eye Surgeon in private practice in Progressive Vision and in public practice in the Royal Victoria Eye and Ear Hospital and St James’s Hospital, Dublin, Ireland.