Most people file eyelid surgery under cosmetic. A good deal of it is not. The eyelid is a working part of the eye: it spreads the tear film with every blink, pumps used tears into the drainage duct, and shields the cornea while you sleep. When a lid stops doing those jobs, the surface of the eye pays for it, and what began as a cosmetic-looking complaint ends up as blurred vision, chronic irritation or, in the worst cases, a corneal ulcer.
Oculoplasty is the branch of ophthalmology that deals with the structures around the eye rather than the eye itself: eyelids, tear drainage, the orbit, and the socket. Here is what we actually see in clinic, and what can be done about each.
The problems that bring people in
The lid that has dropped
Ptosis, a drooping upper lid, has several causes. In older adults the commonest is simply that the tendon lifting the lid has stretched and slipped, often after years of eye rubbing, contact lens wear or previous eye surgery. The lid sits lower, the eye looks smaller, and people find themselves lifting their eyebrows all day, which brings a forehead ache by evening.
It becomes a vision problem when the lid crosses the pupil and clips the top of your visual field. The test is simple: if you tip your chin up to see a road sign or the television, the lid is in the way. Surgery tightens or reattaches the tendon through a crease incision, usually under local anaesthesia. Two points of honesty. Perfect symmetry between the two lids is a goal, not a promise, and small revisions are occasionally needed. And a ptosis that appeared suddenly, or comes with double vision, or is worse at night than in the morning, is a different animal altogether and needs investigation before anyone books a theatre slot.
The lid that has turned
An entropion turns the lid margin inwards, so the lashes scrape the cornea with every blink. It feels like permanent grit. Patients often spend months on lubricants and antibiotic drops for what they have been told is an infection. Lashes rubbing a cornea for long enough will scar it, and that scarring does not reverse.
An ectropion turns the lid outwards, so the lower lid falls away from the eyeball. The eye waters constantly because the drainage opening is no longer in contact with the tear lake, and the exposed inner surface becomes red and thickened.
Both are usually caused by age-related laxity of the lid, sometimes by scarring or by facial nerve weakness. Both are corrected by a short day-care procedure that tightens and repositions the lid. This is one of the most satisfying operations in ophthalmology, because years of discomfort often end in a week.
The eye that will not stop watering
A watering eye is a plumbing question. Either the eye is producing too much, or it is not draining. Too much production is usually caused, oddly enough, by dryness: a poor tear film irritates the surface, and the eye responds with a flood of reflex tears. That is treated medically, not surgically, and you can read more about it on our general eye care page.
The other half is blocked drainage. Tears leave through tiny openings at the inner corner of each lid, down a duct into the nose. When that duct blocks, tears spill onto the cheek all day, and if the sac above the block gets infected, a tender swelling appears at the inner corner. A blocked duct is confirmed by syringing the passage in clinic, and it is opened by a dacryocystorhinostomy, which creates a new channel into the nose. It can be done through a small skin incision or endoscopically through the nostril with no external scar. Success rates are high, and it is one of the few eye operations where the relief is immediate and obvious.
Lumps on the lid
Most lid lumps are a chalazion, a blocked oil gland. Warm compresses twice a day for a few weeks clear a fair number of them, and a small incision under local anaesthesia clears the rest in ten minutes. What matters is knowing which lumps are not chalazia. A lump that keeps recurring in exactly the same spot, one that destroys the lid margin or the lashes over it, one that bleeds or ulcerates, or one growing steadily in an older patient, needs a biopsy rather than another course of compresses. Lid cancers are uncommon, they are very treatable when caught early, and they are missed mainly because they were assumed to be a stubborn stye.
Children have their own list
Two conditions dominate. The first is a congenital blocked tear duct, which is common in newborns and causes a watering, sticky eye from the first weeks of life. Most open on their own during the first year with nothing more than correct massage over the tear sac, which we will teach you to do properly. If it has not settled by around a year, a simple probing under brief general anaesthesia usually sorts it out.
The second is congenital ptosis, and this one has a clock on it. A lid that covers a child's pupil blocks that eye's visual development, and the brain can permanently favour the other eye, which is amblyopia. The same applies to lids so heavy that the child adopts a chin-up posture. Congenital ptosis therefore needs assessment early, not at school age, and is often managed alongside paediatric eye care and, where relevant, squint treatment, since the two can travel together.
Where cosmetic and functional overlap
Some of this work genuinely is cosmetic, and we say so. Baggy lower lids with no functional consequence, mild upper lid hooding that does not touch your field of vision, and lid asymmetry you notice only in photographs are all reasonable things to want corrected and none of them are medically necessary. We will tell you which category you fall into, and if you are in the cosmetic one, we will also tell you it is entirely reasonable to do nothing.
The line between the two is drawn by measurements and a visual field test with the lid taped up and then untaped, not by opinion. If your field improves measurably when the lid is lifted, the problem is functional.
If you have a lid that has dropped, an eye that waters every day, lashes touching the cornea, or a lump that has not settled in six weeks, book a consultation and let someone measure it. Details are on the oculoplasty page, and appointments can be made at Masab Tank or any of our other centres on 90001 80035.
