Cosmetic Appearance After Eye Loss: The Role of Prosthesis Motility and Eyelid Function

Background/Objectives: We aimed to clarify which clinical and prosthetic features are most strongly associated with cosmetic appearance after eye loss. Methods: This prospective cross-sectional study included 107 patients with unilateral anophthalmia wearing acrylic prostheses. Examiner-rated cosmetic outcomes—eyelid symmetry, orbital fullness, prosthesis recognizability, and overall appearance—were graded by three independent raters. Candidate predictors associated in univariate analysis (p ≤ 0.10) were entered into blockwise multivariable regression across four domains: clinical background, socket and eyelid anatomy, prosthesis alignment and motility, and prosthesis dimensions. Results: Levator function (β = 0.19, p = 0.02) and prosthesis motility (β = 0.68, p < 0.001) predicted eyelid symmetry (R2 = 0.61). Orbital fullness was predicted by relative exophthalmometry (β = 0.27, p = 0.039) and motility (β = 0.34, p = 0.002; R2 = 0.34). Recognizability was predicted by motility (β = 0.55, p < 0.001) and history of additional periocular surgery (β = −0.22, p = 0.008; R2 = 0.46). General appearance was predicted by lagophthalmos (β = −0.38, p < 0.001) and motility (β = 0.35, p < 0.001; R2 = 0.69). Prosthesis dimensions were not independently associated with any of the outcomes. Conclusions: Cosmetic appearance after eye loss was most strongly associated with dynamic anatomical features. Prosthesis motility consistently predicted all appearance domains, while upper-eyelid function was associated with symmetry and overall impression. In contrast, background and static anatomical or prosthesis features showed limited independent associations once dynamics were accounted for. These findings highlight prosthesis motility and eyelid dynamics as important considerations in rehabilitation and routine follow-up, while cosmetic outcome assessment should incorporate dynamic features alongside conventional static measures.