Purpose  To report ocular surface findings in eyes manifesting senile sunken upper eyelids.

Design  Crossectional comparative case series

Participants  A study group of 38 eyes of 38 patients with sunken upper eyelids was compared to a control group of 26 age- and gender-matched patients without sunken upper eyelids.

Methods  Patient records were retrieved and compared between the two groups and among different severities of sunken upper lids.

Main Outcome Measures  Ocular surface deficits were measured by symptoms, eyelid blinking and closure, Bell’s phenomenon, apposition of lids and puncta to the globe, conjunctiva inflammation and chalasis, corneal epithelial breakdown by fluorescein and Rose-Bengal staining, and the fluorescein clearance test.

Results  Ocular irritation or pain was less common but tearing and mucous build up were more common in the study group than the control group, and tended to be worse in the morning. Incomplete blinking, incomplete closure, abnormal Bell’s phenomenon, lid/punctum ectropion and delayed tear clearance were more frequently detected in the study group than the control group, and were more evident in severe eyes. Incomplete blinking was significantly correlated with incomplete closure while abnormal Bell’s phenomenon was significantly correlated with early morning symptoms. Conjunctivochalasis was less common in the study group than the control group. Corneal epithelial breakdown was more common in the study group than the control group, and more severe in severe eyes.

Conclusion  Sunken upper eyelids are associated with ocular surface morbidity characterized by corneal epithelial breakdown because of an array of ocular surface deficits leading to exposure and desiccation not only during the day but also in the night. Recognition of this potential risk factor will help understand pathogenesis and formulate effective therapies in complex ocular surface diseases.