Acquired blepharoptosis (ptosis) is the abnormal drooping of the upper eyelid, potentially impairing vision and quality of life. While surgical repair is generally effective, recurrence remains a concern, influenced by patient factors, surgical technique, and ocular comorbidities [1, 2]. Intraocular surgery is a known cause of new-onset ptosis, due to factors like speculum use, bridle sutures, anaesthetic toxicity, and eyelid traction [3, 4]. Despite advances in surgical technique, the long-term effect of intraocular surgery on previously repaired ptosis has not been well studied. If intraocular surgery can induce ptosis in anatomically intact eyelids, it may similarly compromise the integrity of prior repairs, increasing the risk of recurrence and reoperation.

We conducted a retrospective cohort study using the TriNetX research network (Supplement Material) [5]. Patients aged ≥50 years who underwent ptosis repair were included and grouped into two cohorts: the Ptosis Repair with Intraocular Surgery (PRIOS) cohort, comprising patients who subsequently underwent their first intraocular surgery within 1 month to 10 years after ptosis repair, and the Ptosis Repair Only (PRO) cohort, comprising patients with no recorded intraocular surgery during the 10 years after ptosis repair. Patients with neurologic, traumatic, or congenital ptosis were excluded. The primary outcome was reoperation for recurrent ptosis.

A total of 1602 patients were included in the PRIOS cohort, and 12,093 in the PRO cohort before matching. After 1:1 propensity score matching, 1598 patients were retained in each group (Table 1). The mean follow-up time was 597.1 days (SD, 227.5) in the PRIOS cohort and 543.7 days (SD, 265.7) in the PRO cohort. At 2 years, reoperation for recurrent ptosis occurred in 38 vs. 16 patients, corresponding to incidence rates of 14.5 and 6.7 per 1000 person-years, respectively. The absolute risk of reoperation was 2.4% in PRIOS compared with 1.0% in PRO (risk difference, 1.4%; 95% CI, 0.5–2.3%; p = 0.003). Kaplan–Meier analysis demonstrated a significantly higher cumulative incidence of reoperation in the PRIOS cohort, with early separation of the curves (Fig. 1). The hazard ratio (HR) for reoperation was 2.16 (95% CI, 1.21–3.88). The E-value was 3.74 for the HR and 1.70 for the lower bound. The association remained significant at 5 and 10 years, with reoperation rates of 12.3 vs. 6.3 and 11.0 vs. 7.0 per 1000 person-years in the PRIOS and PRO cohorts, respectively. Hazard ratios were 1.98 (95% CI, 1.27–3.10) at 5 years and 1.67 (95% CI, 1.12–2.48) at 10 years, with corresponding E-values of 3.37 and 2.73. Kaplan–Meier curves for both timepoints are presented in the Supplemental Material.

Fig. 1: Kaplan–Meier analysis of cumulative incidence of reoperation for recurrent ptosis.
figure 1

This Kaplan–Meier curve depicts the cumulative incidence of reoperation for recurrent ptosis in the PRIOS (Ptosis Repair with Subsequent Intraocular Surgery) and PRO (Ptosis Repair Only) cohorts over time (months). The PRIOS cohort (red) demonstrated a higher cumulative incidence compared to the PRO cohort (blue), with a hazard ratio of 2.16 (95% CI, 1.21–3.88; log-rank p = 0.008). Shaded areas represent 95% confidence intervals.

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Table 1 Baseline characteristics of patients undergoing ptosis repair with intraocular surgery (PRIOS) vs. ptosis repair alone (PRO), before and after propensity score matching.
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This multicentre retrospective cohort study found that intraocular surgery following ptosis repair is associated with a significantly increased risk of reoperation, with a sustained effect at 2, 5, and 10 years. The observed twofold increase aligns with prior evidence implicating intraocular surgery in ptosis repair failure. A recent multivariate analysis identified intraocular surgery as a potential risk factor for ptosis repair failure; however, its findings were limited by low power and a broad failure definition that included patient or physician dissatisfaction, potentially capturing cosmetic dissatisfaction rather than clinically significant recurrence requiring reoperation [2].

Kaplan–Meier analysis showed higher cumulative reoperation incidence in the PRIOS group, with earlier onset (∼3 months vs ∼6 months), supporting the hypothesis that intraocular surgery may compromise repair durability. Despite the elevated relative risk, the absolute reoperation rate remained low, underscoring clinical relevance while warranting measured interpretation during patient counselling.

Study limitations include the retrospective design, lack of laterality data, and absence of surgical detail or procedure stratification. Nonetheless, the study is strengthened by a large, matched cohort, extended follow-up, and the use of reoperation as a specific, objective outcome reflective of clinically significant recurrence.

In conclusion, intraocular surgery following ptosis repair is associated with a significantly increased risk of reoperation. These findings support incorporating recurrence risk into preoperative discussions and may inform surgical sequencing in patients undergoing both eyelid and intraocular procedures.

Summary

What was known before

  • Acquired blepharoptosis can recur after surgical correction, influenced by surgical technique, patient factors, and ocular comorbidities.

  • Intraocular surgery is a recognized cause of new-onset ptosis due to mechanical and anesthetic factors.

  • Prior studies have suggested an association between intraocular surgery and ptosis repair failure, though evidence has been limited and methodologically heterogeneous.

What this study adds

  • Intraocular surgery after ptosis repair is associated with a significantly increased risk of reoperation for recurrent ptosis, with hazard ratios of 2.16 at 2 years, 1.98 at 5 years, and 1.67 at 10 years.

  • Kaplan–Meier curves show earlier and sustained separation in the PRIOS group, suggesting reduced repair durability following intraocular surgery.

  • The association persists despite low absolute reoperation rates, emphasizing clinical significance while supporting balanced patient counseling.

  • This is the largest study to date to quantify the long-term risk of ptosis repair failure following intraocular surgery using a matched real-world cohort and objective surgical outcome.