Glaucoma drops and your eyelids: a sunken upper lid, longer lashes and a droopy look

Some glaucoma drops can change the look of the eyelids as well as lower the eye pressure. The change has a name, prostaglandin-associated periorbitopathy, which means changes in the tissues around the eye linked to prostaglandin analogue eye drops, the most widely used class of glaucoma drops. This page explains what people notice, how often it is reported, whether it can reverse and why an eyelid surgeon needs to know. It rests on one rule: never stop or change glaucoma drops on your own.

What is prostaglandin-associated periorbitopathy?

It is a group of changes in and around the eyelids that can follow the use of prostaglandin analogue eye drops, usually shortened to PAP. The Medsafe Prescriber Update from New Zealand describes it as clinical and cosmetic changes in the eye associated with these drops, and says the evidence shows the risk is a class effect, meaning it belongs to the whole family of drops and not to one product.

The changes come from the tissue behind and around the lid. These drops work by increasing the fluid leaving the eye, which lowers the pressure that damages the optic nerve in glaucoma. The same signal, acting on receptors in the orbital fat, appears to switch off the cells that build fat. Medsafe and EyeWiki both describe the likely result as orbital fat atrophy, which means the fat cushion shrinks. The eyelid and the eye then sit on less support. The upper lid hollows, the eye can settle a little further back, and the lower lid loses its softness.

Orbital fat is the soft padding that fills the bony socket around the eyeball. Its loss is why this page sits beside my article on a sunken eye, where PAP is one of the causes to be separated from injury, sinus disease and ageing.

What changes might I notice around the eyes?

You might notice a deeper groove under the brow, a hollow upper lid, a lower lid that looks flatter, a lid that sits lower or feels tighter, longer and darker lashes, and darker skin on the lid. Not everyone has all of these, and most people notice only one or two.

Medsafe lists the full set as deepening of the upper eyelid sulcus, which is the groove between the lid and the brow bone, flattening of the lower eyelid bags, upper eyelid ptosis, orbital fat atrophy, mild enophthalmos, a lower lid that sits slightly away from the eye so more white shows beneath the iris, a tight orbit, longer lashes, darker skin around the eye and redundant eyelid skin. EyeWiki adds more visible lid vessels and tight eyelids, and notes that longer lashes and darker iris and lid skin are known effects of these drops that may fit under the same heading.

The change is easiest to see when only one eye is treated, because the other eye acts as a control. When both eyes use the drop the change is symmetrical, so it is easy to put it down to ageing or tiredness. EyeWiki says it may be missed for that reason, and that patients most often describe it as "tired-appearing eyes". Photographs from before the drops began are the most useful thing you can bring to an appointment.

How common are these changes in people on glaucoma drops?

Common enough that they should be expected and looked for, though no one figure fits everyone. EyeWiki states that the true proportion is unknown but that it is not rare. The figures depend on which drop, how long it has been used and how carefully the lids are examined.

A study from Korea gives one real-world picture. Kim and colleagues examined photographs of 58 glaucoma patients who used a prostaglandin analogue in one eye only, with the other eye as the comparison. Two oculoplastic specialists graded the pictures. Thirty-one patients, 53.4 per cent, showed at least one periorbital change. The most frequent was a deeper upper sulcus in 24.1 per cent, then lid pigmentation and lid redness in 19.0 per cent each, redundant lid skin in 10.3 per cent, lid retraction in 5.2 per cent and ptosis in 3.4 per cent. A deeper sulcus was linked to older age and longer use of the drop.

That was a small study in one population, so it shows a pattern and not a rate to apply to yourself. Medsafe adds that the risk is likely to be highest for one drop in the class and lowest for another, and that changes can appear as early as one month after starting. Which drop you use is something only your own doctor can weigh up.

Can the changes reverse if the drops are changed?

Often partly or fully, according to the sources, but that decision belongs to the eye doctor managing the glaucoma and not to you. Medsafe says the changes may be partially or fully reversible on stopping or switching to alternative treatment. EyeWiki says reversal has been seen within weeks in case reports and that a switch to another prostaglandin analogue helped in a small prospective study, where 11 of 13 patients who had PAP on one drop had fewer or no signs after two months on another.

Both sources are describing what can happen in a controlled setting, with the glaucoma doctor watching the pressure the whole time. Neither says it is safe to stop. Glaucoma damage to the optic nerve is permanent, and it usually causes no symptoms until a lot of sight has gone. A lid that looks hollow is a cosmetic and functional worry. A pressure that rises unseen is a threat to vision.

So the safe sequence is this. Tell the doctor who manages the glaucoma what you have noticed. They can measure the pressure, check the optic nerve and visual fields, and decide whether the benefit of your current drop outweighs the change. If it does not, they may consider an alternative drop or another type of treatment. Some people cannot change because their pressure is controlled only by this class, and for them the eyelid change is a trade-off that is explained and monitored. Keep every glaucoma appointment, and do not stop the drops or skip doses yourself.

Why does it matter before eyelid surgery?

Because these drops can change the lid, the tissue behind it and the way a lid operation behaves, and a surgeon cannot plan well without knowing you use them. Tell the surgeon the name of every eye drop you use, even if you think the lids and the drops are unrelated.

There are three reasons. First, PAP can mimic or add to ptosis, the medical name for a droopy lid. Both Medsafe and EyeWiki list ptosis among the features, and Medsafe notes the changes may impair the field of vision. A lid that has dropped after years of drops needs a different explanation from an ageing lid, and a surgeon checks the lid height, the lifting muscle and the position of the eye to tell them apart. I set out the main causes in my article on ptosis that is not ageing.

Second, drop use may affect how well ptosis surgery lasts. In a retrospective study of 240 adults, 404 eyelids, from Baylor College of Medicine, chronic topical prostaglandin use ranked as the strongest predictor of failure of ptosis repair, ahead of chronic steroid drops. The authors called it the highest known risk factor for repair failure with the two operations they studied. It is one centre and a retrospective design, so it does not prove cause, but it is a good reason for the conversation. I discuss the full list of risk factors in my article on whether ptosis surgery lasts.

Third, a sunken lid can make a pressure check harder. EyeWiki notes that applanation tonometry, the standard way of measuring eye pressure, becomes harder in a deeply sunken orbit. That matters to the glaucoma doctor and is another reason to keep both doctors informed. If your glaucoma doctor and your eyelid surgeon are different people, each should know what the other is doing.

EyeWiki also states that surgery, filler or fat grafting is not currently recommended for PAP itself, since the signs seem to settle when the drop stops. Whether and when to operate on a person who must stay on the drop is a decision for the glaucoma doctor and the surgeon together, and an article cannot make it for you. A hollow eye is not the same problem as the age-related tear trough, which I explain in my page on tear trough hollowing, and the same filler logic does not carry across. Not every glaucoma drop works this way. A different family, the alpha-agonist drops, is used for the opposite problem, a lid that droops for a few weeks after anti-wrinkle injections, as Dr Ong Jin Khang sets out in the eye drops that lift a droopy eyelid after Botox, and how long the droop lasts. My eyelid conditions page sets out the wider picture of how a hollow or drooping lid is assessed.

What should I do if I think my drops have changed my eyelids?

Keep using the drops exactly as prescribed, take dated photographs from the front and the side in the same light, and book a visit with the doctor who manages your glaucoma. Ask three things: whether the change fits PAP, whether your pressure would allow a different drop, and what monitoring you need either way.

Bring a list of every eye drop you use, including the ones for dry eye. If a lid is dropping enough to block your upper view, say so, because that is a separate problem that an oculoplastic assessment can address. If you are thinking of eyelid surgery, say that too, and consider a second opinion before eyelid or orbital surgery so that the drop history is weighed properly. For the wider picture of why eyes look tired, I have gathered the causes in my guide to tired-looking eyes, and if your lashes have changed in the other direction, my article on lash and eyebrow loss covers what else to consider.

Dr Catherine Chow will begin consulting at Eagle Eye Centre Malaysia in Petaling Jaya in early 2027. This article is general education and cannot say whether your drops are the cause of any change in your own eyes.