Babies & first checks

My newborn's eyelid will not fully open, what does that mean?

A newborn eyelid that sits lower than the other, or will not open fully, is usually one of three things: ordinary swelling from the birth itself, a lid muscle that did not finish developing, or something underneath pressing on it. Here is how to tell them apart.

by Dr Chan Li Yen · MBBS, MOphth (UM), Fellowship in Paediatric Ophthalmology & Strabismus

Practises at Hospital Kuala Lumpur 12 min read · 2,089 words

Key takeaways

In the first days after birth, a puffy eyelid that settles over days while the eye opens normally underneath is a common and usually harmless story.
What matters is not how swollen the lid looks but whether it covers the pupil, whether the two pupils look the same size, and whether this started at birth or started recently.
A lid that has been low since birth and does not cover the pupil is usually watched, not rushed to surgery.
A droop that is new rather than present from birth, or comes with pupils of different sizes, is seen urgently rather than at the next routine appointment.
A raised, growing birthmark on the lid, or one that is starting to cover the pupil, is also worth a look, separately from a plain droop.

Almost every week, a parent brings in a newborn whose eye has not opened properly since birth, convinced on very little sleep that something has gone badly wrong. Often what we find is ordinary birth swelling, settling exactly as it should, with a perfectly normal eye underneath once we get a proper look. What I want to give you here is not a reason to relax completely, because sometimes the lid genuinely is the problem, but a way of telling the two situations apart before you arrive.

Is a puffy eyelid at birth normal?

Very often, yes. The process of being born is not gentle on a small face, and a lid that looks bruised, puffy or half shut in the first days of life is a story I hear constantly and one that usually resolves on its own. The lid softens and lifts over the following days as the swelling from birth itself goes down, and the eye underneath, once you can properly see it, is normal.

What I would ask you to watch is not the puffiness itself, which can look alarming in a photograph, but three specific things: whether the pupil, the dark centre of the eye, is covered or clear; whether the two pupils look the same size as each other; and whether this is something that has been present since birth or something that has started more recently. Those three questions do almost all of the sorting, and you can check the first one yourself in ordinary daylight, without any equipment. Look at where the dark centre of the eye sits against the edge of the lid. If you can see it clearly, that already tells you a great deal.

Many eyelid problems in a newborn are, genuinely, not serious. Puffiness that follows a straightforward birth, or a small mark that appeared from a minor bruise during delivery, tends to settle on its own without needing anything done to it at all. That is the ordinary, unremarkable story behind most of the newborn eyelids I am asked to look at, and it fits the same pattern as everything else worth knowing about a baby's first eye checks: most of it is watching and reassurance, with a small, specific list of things that change that.

How do I tell ordinary swelling apart from a lid that will not open properly?

Ordinary birth swelling tends to affect the whole area around the eye rather than just the lid margin, softens visibly from day to day, and leaves an eye underneath that looks and moves normally once you get a glimpse of it. A lid that will not fully open because the muscle that lifts it did not develop properly, what we call congenital ptosis, tends to look different: the lid margin itself sits low in a fairly consistent way, day after day, rather than gradually lifting as swelling would.

The pupil is the detail that actually matters here, more than how droopy the lid looks to your eye. A lid that is low but stays clear of the pupil is a very different situation from a lid that sits over it, even only some of the time. It matters because the pupil is where light enters the eye, and a young baby's visual system is still being built. Some babies with a genuinely low lid also tip the chin up slightly, or work the eyebrows, to see out from under it. That is worth mentioning to whoever examines your baby, because it is usually a sign the lid is truly getting in the way rather than simply sitting a little low.

I have written separately, in more detail, about what a genuinely droopy eyelid from birth means and how it is treated, including why the timing of any treatment is decided by whether vision is affected rather than by an age on the calendar. If you suspect that is what you are looking at rather than passing swelling, that is the fuller picture to read next.

What if the lid has been low since birth and does not cover the pupil?

Then it is checked properly, but not in a hurry. A referral pathway used by eye specialists sorts this presentation, low since birth, pupil not covered, both pupils the same size, by the child's age. In an older child, five or above, it is a sight test at the optician. In a baby or a young child it is a booked appointment at a hospital eye clinic instead, because a lid that is low while sight is still developing is worth measuring properly even when the pupil looks clear. Neither of those is a reason to feel you must be seen today. Both are a reason to mention it at your baby's next check rather than let it drift.

When does a droopy eyelid become urgent?

Two things make it urgent: a droop that started recently rather than being present from birth, and pupils that look different sizes from each other. The same referral pathway that treats a longstanding lid with a clear pupil as unhurried treats those two as an urgent matter, seen that week rather than at the next convenient appointment, and I would ask you to take that seriously rather than waiting to see if it settles. A lid that covers the pupil sits between the two. It is not a same-day emergency, but it does need a hospital eye clinic appointment rather than watching, because a covered pupil is the part that can affect how sight develops.

A red, hot, tender lid, or a baby who seems generally unwell alongside it, is its own separate urgent picture and deserves the same swift response as any unwell newborn would. So does a very red or sticky eye in a baby under one month old, which is treated as urgent in its own right regardless of what the lid itself is doing.

What about a birthmark or raised mark on the eyelid?

It depends entirely on whether the mark is flat and staying the same, which needs nothing done, or raised and growing, which needs a look. It is a different question from a droop, though parents often ask them together, because both can make a lid sit lower or look different on one side. It is also a separate question from the flat, bluish-grey birthmarks that sometimes appear around a baby's eye, which behave quite differently again. What we are discussing here is a raised, fleshy mark on the lid itself. A small, flat mark on the lid that is not covering the pupil and is not growing generally needs no treatment at all. A mark that is raised, distorting the shape of the lid, or growing larger over time, or beginning to sit over the pupil, is worth having assessed, because at that point it is the effect on the pupil and on developing vision that matters, not how the mark looks. A baby who has similar marks on other parts of the body as well as the eyelid is worth mentioning to your paediatrician alongside your eye appointment, since that combination is looked at as a whole by the general paediatric team rather than treated as an eyelid matter alone. None of this is a reason to reach for a treatment yourself in the meantime. Whether a lid birthmark needs treating, and with what, is a decision for the doctor who has actually examined it, not something to search for and start at home.

What matters is not how swollen the lid looks, but whether the pupil is covered.

What happens at the appointment, and how can I help?

Bring two photographs if you can manage it beforehand: your baby's face with the eyes open, and the same face with the eyes gently closed. It sounds like a small thing, but it gives whoever examines your baby something concrete to compare against on the day, and something to measure future change against if more than one visit is needed. Beyond that, there is very little preparation required. Nothing about examining a newborn's eyelids is uncomfortable for your baby, and for many families the appointment ends with the reassurance that what looked alarming on day two was the ordinary business of being born.

And when it is not simply that, you have caught it at the earliest possible point, which is exactly where a lid problem is easiest to manage well. Either outcome is a good reason to have asked. The first days of a child's life are full of things that look dramatic and turn out to be nothing, and a handful of things that look small and are worth catching early. A newborn eyelid that will not fully open belongs, genuinely, to both categories, and the only way to know which one you are looking at is to have it seen rather than to guess from a photograph at midnight.

Don't wait for a check-up if…

The lid covers all or most of the pupil, even sometimes.
The droop is new rather than present since birth, or is getting worse rather than staying the same.
The two pupils look different sizes from each other.
The eyelid is red, hot, tender, or your baby seems unwell with it.
There is a birthmark on the lid that is raised, growing, or starting to sit over the pupil.

Common questions

My newborn's eye is swollen shut, is that from the birth?

Often, yes. A lid can be genuinely puffy in the first days of life simply from the process of being born, and swelling that settles over days while the eye opens normally underneath it is the common, reassuring story. What to watch is not the puffiness itself but whether the pupil stays covered as the days pass, and whether the eye underneath looks and moves normally once you can see it.

One eyelid does not open as wide as the other, is that serious?

Usually not, but it is worth a proper look rather than a guess from how it appears in photos. If the lid has been low since birth and it does not cover the pupil, that is generally watched rather than treated urgently. If it started recently rather than at birth, or the two pupils look different sizes, that combination is seen urgently rather than at a routine appointment.

How many days before I should worry about a puffy eyelid in a baby?

There is no fixed number of days I can honestly give you, because it depends on the cause rather than the calendar. What changes the urgency is not time passing on its own but whether the pupil is covered, whether one pupil looks bigger than the other, and whether the lid is red, hot or tender rather than simply low. Any of those is worth being seen for rather than waited out.

There is a red or purple mark on my baby's eyelid, does it need treating?

A small, flat mark that does not cover the pupil and is not growing usually needs no treatment at all. A mark that is raised, growing over time, or starting to sit over the pupil is worth having looked at, because in that situation it is the effect on the pupil and on vision that matters, not the appearance of the mark. A baby with similar marks elsewhere on the body is also worth mentioning to your paediatrician.

Will the droopy eyelid affect her sight?

It can, but not automatically, which is exactly why it is checked rather than assumed either way. A lid that is simply low but clear of the pupil is unlikely to interfere with how vision develops. A lid that covers the pupil, even only sometimes, is a different situation and deserves an assessment rather than a wait and see approach at home.

Should I take a photo before the appointment?

Yes, and it genuinely helps. A photo of your baby's face with the eyes open, and another with the eyes gently closed, gives the person assessing your baby something concrete to compare against on the day and, if needed, to track over the following visits.

References

AAPOS · Ptosis · aapos.org
Moorfields Eye Hospital · Ptosis (droopy eyelid), children's eye conditions management · www.moorfields.nhs.uk
Moorfields Eye Hospital · Eyelid haemangioma (birthmark on lid), children's eye conditions management · www.moorfields.nhs.uk
NHS · Eyelid problems · www.nhs.uk

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.