Ocular Surface Recovery Following Corrective Eyelid Surgery: Course, Predictors, and Perioperative Management Implications

Background/Objectives: The aim of this study was to evaluate ocular surface recovery following reconstructive eyelid surgery, to identify preoperative predictors of incomplete symptomatic recovery, and to propose a risk stratification framework to enable targeted perioperative management. Methods: This retrospective multicenter study included 50 eyes of 32 patients (mean age 73.0 ± 13.9 years; 44% female) affected by ptosis (eyes = 23) or ectropion (eyes = 27) who underwent standardized corrective surgery at two Italian centers. Ocular surface evaluation was performed preoperatively (T0) and 1 week (T1), 1 month (T2), and 3 months (T3) postoperatively. Outcomes included the Ocular Surface Disease Index (OSDI) questionnaire, Schirmer I test, non-invasive tear breakup time (NI-BUT), and corneal fluorescein staining (Oxford staining score). Pre-existing dry eye disease (preDED) was defined as OSDI ≥ 23 combined with at least one objective sign using conservative thresholds (NI-BUT < 5 s, Schirmer I ≤ 7 mm, or Oxford staining score ≥ 2). Results: At 3 months, patient-level OSDI decreased by a median of 11.0 points (p < 0.001) and eye-level Oxford staining score by 0.96 grades (p < 0.001, r = 0.870). Ectropion patients achieved greater OSDI improvement than ptosis patients (median 21 vs. 2 points, p = 0.002) yet converged to comparable final values (median 16 vs. 18, p = 0.715). PreDED was identified in 10 patients (32%), all with severe baseline disease (OSDI ≥ 33 plus objective signs). All preDED patients (100%) achieved the minimal clinically important difference (≥7.3 points) versus 33% of no-DED patients (p < 0.001). However, 50% of preDED patients maintained moderate symptoms (OSDI ≥ 23) at 3 months versus 19% of no-DED patients (p = 0.105). Overall, the assessed parameters suggested a biphasic postoperative course, with transient worsening at 1 week, followed by progressive recovery by 3 months. Conclusions: Reconstructive eyelid surgery produces sustained ocular surface improvement within 3 months, yet preDED was associated with incomplete symptomatic recovery despite universal achievement of clinically meaningful improvement. These exploratory findings suggest that patients with severe baseline preDED may benefit from preoperative identification and individualized counseling regarding realistic expectations; whether intensified perioperative management improves outcomes should be tested prospectively. Randomized trials are needed to determine whether preoperative optimization with anti-inflammatory therapy and meibomian gland treatment improves outcomes in this higher-risk subgroup.