The Role of Oculoplastics in Optometry

What does comprehensive eye care really mean in 2025? Giving patients their best possible vision for life goes beyond our traditional training and encompasses care of the periorbital skin, eyelids, and brows. Anatomic changes to the periorbital areas—and our interventions—can ultimately improve vision, as these structures are instrumental in protecting the ocular surface, distributing tear film, and allowing ample light to enter the visual system. Patients are often unaware of how significantly changes in these areas can affect their sight—not to mention the fact that optometry offers a space for these key conversations.

As the lines between eye care and aesthetics continue to blur, optometrists are uniquely positioned to diagnose and discuss early signs of periorbital aging and ocular surface disease and to collaborate effectively with their patients and oculoplastic surgeons. By integrating a comprehensive oculoplastic approach into our patient evaluations, we as optometrists can elevate our patient care, strengthen our value propositions, and deliver aesthetics-based procedures.

THE IMPORTANCE OF A THOUGHTFUL AESTHETIC ASSESSMENT

Patients may present for dry eye, contact lenses, or routine care, but they often harbor unspoken concerns about their appearance. Rarely do they visit their optometrist directly seeking aesthetic treatments, such as neurotoxin injections, energy-based treatments, or eyelid surgery. However, when patients understand our knowledge and expertise, I have found that many are very interested in learning about these treatments.

Moreover, a detailed oculoplastic assessment reveals more than wrinkles—it can uncover hidden pathology, guide treatment, and set realistic expectations. The key is learning to see interested patients through both an optometric and an aesthetic lens. Be intentional with your lifestyle questionnaires and reap the benefits of inviting patients to opt-in to a dialogue about aesthetics.

SKIN EVALUATION: BEYOND THE SURFACE

Facial and ocular rosacea are underdiagnosed in our patient populations.¹ The hallmark features of these conditions (ie, erythema, telangiectasia, papules, and pustules)¹ are often dismissed as cosmetic, yet they can drive ocular inflammation, meibomian gland dysfunction, and tear film instability. Take an investigative approach in your examination by looking for the following:

• Flushing across the cheeks, nose, and forehead
• Visible telangiectasias on the cheeks and lids
• Thickened skin, or rhinophyma, in advanced stages
• Lid margin inflammation with telangiectatic vessels, suggestive of meibomian gland dysfunction
• Collarettes at the base of the eyelashes (most easily seen by having the patient look down; remember, rosacea and Demodex blepharitis have been shown to be correlated²)

Prompt recognition of rosacea allows integrated treatment, such as trigger avoidance, intense-pulsed light (IPL) therapy, topical therapies, antibiotics, and/or skincare regimens.

EYELID EXAMINATION: FORM AND FUNCTION

The eyelids are critical to ocular health and facial symmetry. Patients should be assessed for structural abnormalities that may affect not only their appearance, but also their tear film stability and long-term comfort.

Ectropion and Entropion

Ectropion is an outward turning of the lower lid, which can expose the conjunctiva, leading to irritation, epiphora, and cosmetic asymmetry. Entropion is an inward turning of the lid margin, which can cause lashes to abrade the cornea, leading to chronic redness and/or discomfort.

These conditions often result from involutional changes but may also arise from scarring, facial nerve palsy, or previous surgery. Early recognition can help to prevent complications and facilitate timely referral for surgical correction.

Floppy Eyelid Syndrome

Floppy Eyelid Syndrome (FES) is characterized by laxity of the upper eyelids, causing them to evert easily, especially during sleep. FES is commonly associated with obesity and obstructive sleep apnea, which each carry significant systemic implications.³ Signs to look for include:

• Redundant, rubbery upper lids
• Papillary conjunctivitis on the upper tarsal plate
• Eyelid eversion during slit-lamp manipulation

Patients with FES may experience chronic ocular surface irritation; addressing it may warrant a sleep study and oculoplastic referral. Patients with FES are also at higher risk for stroke and cardiovascular events.⁴

BROW AND EYELID POSITION: SUBTLE SHIFTS, MAJOR EFFECTS

Subtle periorbital changes often precede patient complaints. With age, the brow and upper eyelid descend due to skin laxity, volume loss, and gravitational forces.

Brow Ptosis

Brow ptosis, the descent of the eyebrow below the supraorbital rim, contributes to a heavy or tired appearance. It is often mistaken for upper eyelid dermatochalasis. Patients will often recruit their frontalis muscle to elevate the brows. Look for this tell-tale sign during your assessment. Your evaluation may involve:

• Comparing the brow position relative to the orbital rim
• Observing compensatory frontalis contraction
• Asking the patient to close their eyes gently and then open them without raising their brows

Brow lift procedures, both surgical and minimally invasive, can dramatically restore a youthful appearance and improve function as well as vision.

Dermatochalasis

Excess upper eyelid skin, or dermatochalasis, often develops due to age-related changes in skin elasticity and fat redistribution. Clinical indicators include:

• Hooding of upper eyelid skin, sometimes touching the lashes
• Visual field obstruction, particularly in superior gaze
• Difficulty with makeup application or lid hygiene

When symptomatic, dermatochalasis can be addressed with blepharoplasty, which is often covered by insurance when functional criteria are met.

Blepharoptosis

Drooping of the upper eyelid margin, referred to as blepharoptosis, or simply ptosis, differs from dermatochalasis. True blepharoptosis results from levator muscle dysfunction, most commonly dehiscence, and can be congenital, involutional, neurogenic, or traumatic. Steps to evaluate this area include:

• Measuring the margin-reflex distance
• Comparing lid crease symmetry
• Assessing lid plate show
• Performing levator function testing (excursion from downgaze to upgaze)

Oxymetazoline HCl ophthalmic solution 0.1% (Upneeq, RVL Pharmaceuticals) is a drop that can be used to activate the Müller muscle to increase elevation of the eyelids by 1 mm to 2 mm.⁵ The effects of this drop can last 6 hours or more, and I have found that patients tend to appreciate the noninvasive nature of this treatment. Surgery for ptosis is also an option to correct asymmetry, potentially restoring both function and aesthetics.

SIGNS OF PERIORBITAL AGING: THE AESTHETIC LENS

Aging affects every layer of the periorbital region, including the skin, fat, muscle, and bone. The skin in this area is 0.5 mm thinner than that in the rest of the body, is highly prone to skin cancer and aging,⁶ and is typically the first thing people see when they look at someone’s face. Common findings associated with periorbital aging include:

• Volume loss under the eyes (ie, tear trough deformity), creating a hollowed or tired look
• Steatoblepharon, or fat prolapse, creating under-eye bags
• Skin laxity
• Rhytids (ie, fine lines) and wrinkles
• Hyperpigmentation

While some changes are best addressed surgically (eg, lower lid blepharoplasty), others respond well to less invasive options such as neurotoxin injections, platelet-rich plasma therapy, or treatment with energy-based devices.

INTEGRATING AESTHETIC INSIGHTS INTO CLINICAL PRACTICE

Optometrists don’t need to become cosmetic surgeons to play a meaningful role in their patients’ aesthetic care. A collaborative, medically informed approach not only benefits patients, but also positions your practice as a pillar of comprehensive eye care. Tips for successful integration of ocular aesthetic treatments may include:

• Asking open-ended questions about appearance or vision changes, such as “Have you noticed any changes in your eyelids?” or “How do your eyes look and feel?”
• Using imaging tools you already have available to open up the conversation, such as wide-field photography or meibography.
• Partnering with local oculoplastic surgeons and/or medical aesthetic providers for appropriate comanagement.
• Adding aesthetic treatments such as neurotoxins, IPL therapy, radiofrequency, and/or laser resurfacing of the periocular region to your practice.

SEIZE THE OPPORTUNITY

Recognizing rosacea, lid malposition, changes due to aging, and signs of systemic disease can transform a cosmetic conversation into a clinical evaluation. By broadening our scope to include the aesthetics of the periocular region, we not only serve our patients more holistically, but we also embrace the evolving landscape of modern eye care. I have found ocular aesthetics to be one of the most rewarding expansions of my practice, and with the right preparation, I am confident you will find the same!