Blepharoptosis after Modern Phacoemulsification Cataract Surgery: Incidence, Risk Factors and Underlying Mechanisms

Topic: This is a review of the available literature on blepharoptosis following modern phacoemulsification cataract surgery with intraocular lens (IOL) implantation. Clinical relevance: Blepharoptosis is a frequently underestimated complication of ocular surgery. Methods: This review followed PRISMA guidelines and was prospectively registered in PROSPERO (CRD420261348501). A literature search was conducted in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials, from database inception to February 2026. Studies evaluating postoperative ptosis after modern phacoemulsification with IOL implantation were included. Extracted data focused on the incidence of ptosis and associated risk factors. Results: Eight studies, including a total of 863 eyes, met the inclusion criteria. Five studies reported the exact incidence of ptosis, whereas the remaining studies only compared preoperative and postoperative marginal reflex distance 1 (MRD1). Among studies reporting incidence, rates ranged from 0%-10.7%, with four of the five studies (674/702 eyes, 96%) reporting incidences ≤4.1%. None of the studies comparing preoperative and postoperative MRD1 measurements found a statistically significant difference. Lower preoperative levator palpebrae superioris function and higher preoperative MRD1 were identified as potential risk factors. Conversely, surgical duration and lid speculum type were not consistently associated with ptosis. Studies using exclusively topical anaesthesia reported either no ptosis or no significant change in MRD1. Conclusion: Postoperative ptosis following modern cataract surgery has a low but not negligible incidence. Preoperative eyelid characteristics and the type of anaesthesia may influence its occurrence. Postoperative ptosis should be routinely discussed during preoperative counselling.