Management of Deepening Upper Eyelid Sulcus (DUES)
If DUES is caused by prostaglandin analog therapy for glaucoma, switch from bimatoprost or travoprost to latanoprost, which typically resolves the cosmetic deformity within 2-3 months while maintaining intraocular pressure control. 1
Understanding DUES Etiology and Risk
Prostaglandin-Associated Periorbitopathy
DUES represents a common adverse effect of prostaglandin F2α analogs used in glaucoma treatment, with marked variation in incidence based on the specific agent used. 2, 3
Bimatoprost carries the highest risk, causing DUES in 60% of patients both objectively and subjectively, significantly more than other prostaglandin analogs. 2
The comparative incidence rates across agents are:
- Bimatoprost: 60% (objective) and 40% (subjective) 2
- Travoprost: 50% (objective) and 24% (subjective) 2
- Latanoprost: 24% (objective) and 12% (subjective) 2
- Tafluprost: 14-18% (objective) and 10% (subjective) 2, 3
- Unoprostone: 8% (objective) and 10% (subjective) 2
Risk Factors and Timeline
DUES develops more frequently in older patients and those with non-myopic eyes. 4
The condition typically manifests within 1 month of starting bimatoprost therapy (44% incidence at 1 month), with incidence increasing to 60% by 3-6 months. 4
Therapeutic Algorithm
Step 1: Confirm True DUES vs. Pseudo-DUES
Before attributing eyelid changes to medication, rule out a DUES-like appearance caused by wide-open eyes during examination or photography. 5
The presence of upper eyelid sulcus (UES) with natural open eyes is the strongest predictor of pseudo-DUES (odds ratio 17.2), occurring in 50% of UES-positive patients when photographed with wide-open eyes. 5
This is critical because overestimation of DUES incidence can lead to unnecessary medication changes in treatment-naïve patients. 5
Step 2: Switch to Lower-Risk Prostaglandin Analog
Latanoprost is the preferred alternative agent when DUES occurs with bimatoprost or travoprost, as it has the lowest objective incidence among commonly used prostaglandin analogs and allows resolution of the cosmetic deformity. 1, 2
Three of four patients switched to latanoprost experienced complete resolution of sunken eye appearance within 2-3 months, with no significant changes in intraocular pressure control. 1
One patient who discontinued travoprost for 4 months before switching to latanoprost had no recurrence during 6 months of follow-up. 1
Step 3: Monitor for Resolution
Expected timeline for improvement after switching to latanoprost is 2-3 months. 1
Continue monitoring IOP to ensure adequate glaucoma control is maintained during the medication transition. 1
Critical Clinical Pitfalls
Patient Awareness Discrepancy
Only 53.3% of patients objectively confirmed to have DUES actually notice the condition themselves, meaning many patients may have this side effect without reporting it. 4
Proactive photographic documentation and direct questioning about eyelid changes is essential, as subjective reporting significantly underestimates true incidence. 2, 3, 4
Informed Consent Considerations
Physicians should inform patients about DUES as a potential side effect when prescribing prostaglandin analogs, particularly bimatoprost, before initiating therapy. 2, 3
The cosmetic impact, while generally well-tolerated (only 1 of 15 patients discontinued therapy due to DUES in one study), should be discussed as part of shared decision-making. 4
Photography Technique Matters
When documenting DUES, ensure photographs are taken with natural open eyes in primary gaze, not wide-open eyes, to avoid false-positive assessments. 5
Camera flash effects and patient positioning can create artifactual appearances that mimic DUES. 5