Oculoplastic
Surgical and non-surgical treatment of the eyelids, from drooping lids and excess skin to cholesterol deposits and eyelid spasm.
The eyelids protect the eye, spread the tear film with every blink and frame the field of vision. When a lid droops, or its skin hangs over the lashes, the question is not only how the eye looks. It is how much the eye can still see.
Why eyelids belong to an eye surgeon
Eyelid problems are often treated as skin problems. They are not. The lid sits directly on the eye, and what it does affects vision, tear film and comfort, which is why the assessment starts with an eye examination, not a mirror.
The practical distinction we make at the first visit is functional versus cosmetic. If a lid is blocking part of your field of vision, treating it restores something you have lost. If it is not, the decision is entirely yours and there is no medical pressure to proceed. We will tell you plainly which of the two you are in.
Blepharoplasty: excess upper-lid skin
With age the skin of the upper lid stretches and loosens, a change called dermatochalasis. In mild cases it is a matter of appearance. When the fold hangs over the lashes it starts to cut into the upper part of the visual field, and people compensate without noticing, raising the eyebrows all day, tilting the head back to read a sign.
Blepharoplasty removes the excess skin, and a strip of muscle or fat where needed. It is done under local anaesthetic as a day procedure, with fine sutures along the natural lid crease so the scar settles into the fold.
The brow matters as much as the lid. A heavy eyebrow can push lid skin down and imitate the problem. Operating on the lid alone, when the brow is the cause, gives a disappointing result, so both are assessed together before anything is planned.
Ptosis: a drooping lid margin
Ptosis is a different problem from excess skin, though the two often occur together and are frequently confused. Here the edge of the lid itself sits too low, because the muscle that lifts it has weakened or detached from its attachment. Age is the most common cause; it can also be present from birth, or follow injury.
Early on, the upper field feels blocked. If the lid reaches the pupil, vision through that eye is obstructed outright. In children the stakes are higher: a lid covering the pupil during the years in which sight develops can cause amblyopia, so childhood ptosis is assessed early rather than watched.
Surgery tightens or reattaches the lifting muscle, and is usually very successful.
A lid that droops suddenly, or changes quickly, is different. New ptosis, particularly with double vision, pain, or a pupil that looks the wrong size, can signal a nerve or muscle condition that needs assessment now, not at the next convenient appointment.
Xanthelasma: more than a cosmetic mark
Xanthelasmata are the soft yellowish plaques that form in the skin of the eyelids, usually near the inner corner. They are cholesterol deposits, they do not hurt, and they do not affect vision.
They are worth taking seriously anyway. A Danish population study that followed 12,745 people found that those with xanthelasmata had a meaningfully higher risk of heart attack and ischaemic heart disease, and that this held even after accounting for their cholesterol and triglyceride levels. In other words, the plaque carries information that a blood test alone does not.
So our first step is not removal. It is a lipid profile, and a referral to a physician if it comes back abnormal. The plaques themselves can be removed surgically or with laser, and we will say beforehand that recurrence is common, particularly where the underlying lipid problem is untreated.
Botox for the eyelids
Botulinum toxin is widely known as a cosmetic injection, but in ophthalmology it is first a treatment. It is approved by the US Food & Drug Administration for blepharospasm (the involuntary, forceful closing of the eyelids that can leave someone functionally unable to see) and for strabismus, in patients 12 years of age and older.
Injected into the muscle around the eye, it relaxes the spasm for a period of months, after which the treatment is repeated. The same mechanism softens the lines at the outer corner and between the brows, and we offer that too, as a cosmetic choice, described as one.
What a consultation involves
- Eye examination firstVision, tear film and the surface of the eye, before any discussion of the lids themselves.
- Lid and brow measurementHow low the lid sits, how well its muscle lifts, and whether the eyebrow is contributing.
- Visual field testing where relevantDocuments how much field the lid is taking, and distinguishes a functional problem from a cosmetic one.
- PhotographsA baseline to compare against, and the clearest way to show you what is actually happening.
- A plan, in plain termsWhat can be improved, what cannot, and what the result realistically looks like.
This page is general information, not medical advice. Findings vary from person to person, and only an examination can tell you what applies to your eyes.