Dry eye and blepharoplasty

Causes

• Dry eye in the general population: the Beaver Dam Eye Study found 14.4% prevalence by history in 3,722 adults aged 48-91, rising from 8.4% under 60 to 19.0% over 80, higher in women (16.7%) than men (11.4%); arthritis, smoking, thyroid disease and diabetes were independent risk factors (PMID 10980773).
• A 2013 US national survey estimated 6.8% of adults (about 16.4 million people) have diagnosed dry eye disease, 8.8% of women versus 4.5% of men, rising from 2.7% at ages 18-34 to 18.6% at 75 and older (PMID 28705660).
• The TFOS DEWS II Epidemiology Report puts global dry eye prevalence at 5-50% depending on the diagnostic definition used, higher in women and with age, with Asian ethnicity a consistent risk factor (PMID 28736337).
• Mechanism: blepharoplasty and ptosis repair can produce transient lagophthalmos and altered blink parameters; in 55 young women, blink count fell and partial-blink rate rose in the first week after transcutaneous upper blepharoplasty before returning to baseline at 1 month (PMID 34881256).
• Removing preseptal orbicularis oculi muscle with skin, rather than skin alone, raised lagophthalmos odds nearly eightfold in a meta-analysis of randomized trials (OR 7.98, 95% CI 1.41-45.21), without raising overall dry eye incidence (OR 1.55) (PMID 40152471).
• A 2026 review frames oculoplastic surgery, including blepharoplasty, as introducing "mechanical alterations that disrupt eyelid function and tear film distribution," alongside refractive surgery, cataract surgery and periocular cosmetic injections as iatrogenic dry eye causes (PMID 42343584).

Screening and diagnosis

• The TFOS DEWS II Diagnostic Methodology report sets the standard sequence: symptom screening with the OSDI or DEQ-5 questionnaire, then tear break-up time (TBUT), osmolarity and ocular surface staining with fluorescein and lissamine green, then meibomian gland assessment to classify disease as evaporative or aqueous-deficient (PMID 28736342).
• Schirmer test and TBUT are the two measures used across the blepharoplasty and ptosis literature to track tear production and film stability before and after surgery (PMID 34612583), (PMID 36972140).
• A 2019 commentary asked directly whether a Schirmer test should be routine before blepharoplasty, a question the literature has not settled (PMID 30408185).
• A retrospective review of 202 patients undergoing upper and/or lower blepharoplasty built a preoperative risk-detection and management algorithm around identifying patients with baseline dry eye risk factors before surgery (PMID 19116572).
• Patients with a history of LASIK or PRK need corneal sensation, tear production and tear film specifically assessed before blepharoplasty, since keratorefractive surgery alone can cause dry eye that blepharoplasty then compounds (PMID 32487809); guidance suggests waiting at least 6 months after laser vision correction before blepharoplasty (PMID 18626378).

Results and evidence

Incidence and risk factors

• The largest series: 892 upper or lower blepharoplasty cases over 10 years by one surgeon found dry eye symptoms in 26.5% and chemosis in 26.3% of patients. Concurrent upper and lower blepharoplasty and skin-muscle flap technique raised both risks (P<.001 and P=.001). Hormone therapy use and preoperative scleral show were associated with dry eye symptoms (P<.05); postoperative lagophthalmos was associated with dry eye symptoms (P<.001); intraoperative canthopexy was associated with chemosis (P=.009) (PMID 23329270).
• A meta-analysis of 12 randomized trials in 450 upper blepharoplasty patients found dry eye symptoms fell after surgery overall compared with preoperative status (OR 0.22, 95% CI 0.13-0.36) (PMID 40152471).
• Of 42 eyes graded on the Oxford ocular-surface staining scale after upper blepharoplasty, 66% had mild symptoms, 23% moderate and 9% marked; none were severe, and Schirmer score was significantly lower at 3 months than at any preoperative measure (PMID 35098083).
• An AS-OCT study of 50 patients found OSDI, Schirmer, TBUT and tear meniscus height worsened at 1 month and then improved at 3 and 6 months, returning to or surpassing baseline; 95% of patients reported satisfaction with the cosmetic outcome (PMID 40453787).
• A randomized trial of 54 patients found subjective ocular irritation improved after upper blepharoplasty regardless of technique, while objective tear dynamics were unchanged at 12 months; the muscle-excision group had a transient rise in tear osmolarity and TBUT at 6 months only (PMID 34612583).

Time course after upper blepharoplasty

• In 120 patients (DEWS II criteria: OSDI ≥13, NIBUT <10s), dry eye rate was 12.5% preoperatively, 12.5% at 1 week, 32.5% at 1 month, and 16.67% at 3 months (PMID 32696159).
• In 100 eyes, meibum quality, gland expressibility, OSDI and incomplete blink rate worsened at 1 week and 1 month (all P<.001) and recovered by 3 months; TBUT, staining, Schirmer, lipid layer thickness and gland dropout did not change significantly at any point (PMID 42286332).
• An AS-OCT study of 102 eyes found OSDI, tear meniscus depth and area rise within the first 10 days, with no change in Schirmer or non-invasive TBUT, and no differences beyond 10 days (PMID 42671641).
• Corneal nerve fiber density fell transiently at 1 week in skin-only and muscle-resection groups (24 eyes each), returning to baseline by 1 month and 1 year; meibomian gland area loss increased at 1 year in both groups regardless of technique (P=.030 skin-only, P=.023 muscle) (PMID 36972140).
• In 22 eyes, OSDI and corneal/conjunctival staining rose and TBUT fell at 1 and 6 months (P≤.003 for all); Schirmer score did not change (PMID 38537039).
• Preexisting dry eye is itself a risk factor for worse and more persistent postoperative damage: in 20 patients, those with preexisting dry eye had tear film instability (NIKBUT, TBUT) persisting through 6 months, while those without it recovered by 1 month; tear IL-8 and TNF-alpha rose only in the preexisting-dry-eye group (PMID 34957146).
• In 32 eyes across three groups, Schirmer score fell at 6 months after blepharoplasty alone and after blepharoplasty with levator advancement, but not after ptosis repair alone; TBUT fell only transiently (1 week) in the ptosis-alone group (PMID 35196840).
• In 60 eyes, TBUT and dry eye rate (TBUT <10s) improved at 1 month (P=.024, P=.027), while corneal hysteresis fell significantly at 1 and 3 months (PMID 39306627).

Ptosis repair

• MMCR added to blepharoplasty: at day 90 in 54 patients, the MMCR group had significant increases in lissamine-green and fluorescein staining (P=.05, P=.02) and OSDI (25.38 versus 17.24 preoperatively, P<.01); the blepharoplasty-alone group showed no change (PMID 31770512). The same group followed 40 patients long-term (mean 4.94 years post-MMCR versus 4.22 years post-blepharoplasty) and again found significant staining increases (P<.01) and a TBUT decrease (P=.044) only in the MMCR group (PMID 38221896).
• A smaller, earlier study reached the opposite conclusion: in 46 patients, adding MMCR to skin excision did not worsen Schirmer, TBUT or staining scores versus skin excision alone at 90 days (PMID 27824507).
• Levator advancement alone (no MMCR): in 30 eyes with no prior dry eye history, meibomian gland loss, TBUT, staining, tear meniscus height and Schirmer score did not change significantly at 21-28 days; OSDI rose from 16.094 to 24.296, not significantly (P=.107) (PMID 37791836).
• Baseline tear oxidative stress markers were higher in 62 patients with dermatochalasis or blepharoptosis than in 32 controls (P<.001); after conjunctiva-Müller muscle resection, oxidative stress rose and TBUT fell transiently at 1 month; Schirmer and OSDI were unchanged in both groups (PMID 38836622).
• In 92 patients split into ptosis-alone, ptosis-plus-blepharoplasty and blepharoplasty-alone groups, dry eye symptoms rose temporarily in the two ptosis groups, most at 1 and 3 months in the combined group, and returned near baseline by 6 months in all groups (PMID 40141678).
• Tear meniscus radius fell after levator advancement in 59 eyes (0.31mm to 0.23mm, P<.001; 78% of eyes), more so with higher preoperative tear volume (PMID 24212766); in 83 unilateral ptosis patients, Schirmer and TBUT both declined over 6 months, and those reporting dryness had shorter TBUT (PMID 25474275).
• Conjunctivochalasis worsened in 11 of 64 eyes (17.2%) 6 weeks after levator advancement for involutional ptosis, and worsening tracked with more superficial punctate keratopathy (0.72 versus 0.12, P=.0222) (PMID 38682938).

Risks and complications

• Larger postoperative margin reflex distance (MRD1 and MRD2) and a greater surgical increase in MRD1 were associated with worsening dry eye symptoms after external levator advancement in 190 eyes; patients with preexisting dry eye had worse symptoms preoperatively and at 1 week but not by 3 months (PMID 40327433).
• A randomized trial of 40 eyes found orbicularis resection during combined blepharoplasty and levator advancement had no significant effect on dry eye parameters, appearance or satisfaction versus skin-only excision (PMID 41575571).
• Six patients who underwent both LASIK and blepharoplasty, in either order, all developed exposure keratopathy requiring surgical correction, with symptoms appearing 1 week to 4 months after the second procedure; correcting lid malposition and lagophthalmos improved symptoms in all six (PMID 17519726).
• Eyelid and orbital conditions, including ptosis, orbital fat herniation and ectropion, can change corneal topography and astigmatism as well as predispose to dry eye; full healing after oculoplastic surgery is advised before any subsequent refractive procedure (PMID 32487809).

Recovery

• In the 202-patient review, dry eyes persisting beyond 2 weeks occurred in 22 patients (10.9%) and beyond 2 months in 4 (2%); most resolved with artificial tears, lubrication, steroids and night taping. One patient (0.5%) needed surgical correction after a punctal plug failed. Persistent chemosis occurred in 15 of 22 (68.2%) with symptomatic dry eye (P<.01) (PMID 19116572).
• Authors of the 2026 full-incision blepharoplasty series recommend proactive postoperative dry eye counseling, artificial tears and blink training during the recovery window when meibomian gland function and blink completeness are most disrupted (PMID 42286332).
• For ptosis patients with poor Bell's phenomenon, considered a relative contraindication to surgery because of corneal exposure risk, taped eyelid closure at night managed nocturnal lagophthalmos in 23 patients; only 1 needed reoperation to lower eyelid height for prolonged lagophthalmos (PMID 37697086).

Combined procedures

• Concurrent upper and lower blepharoplasty, and intraoperative canthopexy, both raised dry eye and chemosis risk above a single-lid or single-procedure operation (PMID 23329270); lid-tightening detail is in research/science/canthoplasty-and-canthopexy.md.
• Adding MMCR or anterior levator resection to blepharoplasty produced measurable tear-meniscus and Schirmer declines that blepharoplasty alone did not (PMID 34590166); combining ptosis correction with blepharoplasty produced more pronounced temporary dry eye at 1 and 3 months than either alone (PMID 40141678).
• Procedure technique and anatomy are covered in research/science/upper-blepharoplasty.md, research/science/lower-blepharoplasty.md and research/science/blepharoptosis-repair.md.

Current questions

• Whether orbicularis resection itself worsens dry eye, apart from the lagophthalmos it can cause, is unresolved: a 2025 meta-analysis found higher lagophthalmos odds with resection but no difference in dry eye incidence (PMID 40152471); a 2026 RCT of resection during combined blepharoplasty and levator advancement found no effect on any dry eye parameter (PMID 41575571).
• Whether MMCR meaningfully raises dry eye risk is contested: one group found significant staining and OSDI increases at 90 days and again at a mean of nearly 5 years (PMID 31770512), (PMID 38221896); an earlier, smaller study found no worsening at 90 days (PMID 27824507), and a study of levator advancement without MMCR found no significant change (PMID 37791836).
• Whether a Schirmer test should be routine before blepharoplasty is unresolved; a 2019 commentary raised the question directly without settling it (PMID 30408185).
• The 2025 TFOS DEWS III Digest names iatrogenic dry eye, including surgical eyelid procedures, as its own research category, signaling that standardized pre- and postoperative protocols for eyelid surgery are still being defined (PMID 40472874).
• Objective predictors of worse postoperative dry eye are new: a 2025 study proposed the surgical change in margin reflex distance as one predictor after external levator advancement (PMID 40327433).

Terms

• Dry eye disease (dysfunctional tear syndrome): irritation, burning or blurred vision from an unstable or insufficient tear film (PMID 28736337).
• Schirmer test: a filter-paper strip placed in the lower eyelid that measures tear production over a set time (PMID 28736342).
• Tear break-up time (TBUT): the number of seconds before the tear film breaks up after a blink, measuring tear film stability (PMID 28736342).
• Ocular Surface Disease Index (OSDI): a patient questionnaire that scores dry eye symptoms (PMID 28736342).
• Lagophthalmos: incomplete eyelid closure, which exposes the cornea to air and can trigger dry eye (PMID 40152471).
• Meibomian gland dysfunction: reduced function of the oil glands in the eyelid margin that stabilize the tear film (PMID 42286332).
• Chemosis: swelling of the conjunctiva, the clear membrane over the white of the eye (PMID 23329270).
• Tear meniscus: the strip of tear fluid along the lower eyelid margin, whose height and area reflect tear volume (PMID 24212766).
• Margin reflex distance 1 (MRD1): the distance from the corneal light reflex to the upper eyelid margin, a measure of lid height used in ptosis surgery (PMID 40327433).
• Müller muscle-conjunctival resection (MMCR): a ptosis repair that shortens Müller's muscle from the inside of the eyelid (PMID 31770512).
• Iatrogenic dry eye: dry eye caused by a medical or surgical intervention rather than by an underlying disease (PMID 42343584).

Papers