Bags under the eyes: causes, treatment and when to see a doctor

The most common reason is age-related change. BAAPS explains that the skin loses its elasticity and muscles slacken with age. For the eyelids this results in an accumulation of loose skin that forms deepening creases in the lower lids, and the slackening of the muscle beneath the skin allows the fat that cushions the eyes in their sockets to protrude forward, giving the appearance of bagginess. BAAPS also describes weakening of the orbital septum as allowing fat to bulge forward from inside the eye socket.

Moorfields Private says that hereditary factors and changes with age can cause a drooping of skin and the tissues under the skin, with protrusion of the underlying fat. BAAPS adds that in some families there is an inherited tendency for bags to develop during early adulthood, before any skin changes.

Not all puffiness around the eyes is structural. The NHS says that itchy, flaky, sticky or swollen eyelids may be caused by an allergy, blepharitis or conjunctivitis, and that swelling from a nearby insect bite, injury or operation usually goes away after a week or so. The NHS says a lump or swelling may be a stye or meibomian cyst, and that hot, painful and swollen eyelids can be cellulitis.

Bags that come from fat bulging through the lower lid do not settle with self-care. Surgery is the main permanent treatment. Leeds Teaching Hospitals says the surgical procedure to remove excess eyelid tissues (skin, muscle or fat) is called blepharoplasty, and can be performed on the upper lid, lower lid or both, for either cosmetic or functional reasons.

For the lower lid, Leeds explains that transconjunctival blepharoplasty removes excess fat through an incision inside the lower lid, and that fat may also be moved or transposed rather than removed, particularly if there are pre-existing hollow areas. For lower eyelid surgery it is common to perform other procedures to tighten the lower lid, giving it support and reducing the risk of lower lid retraction and ectropion.

Moorfields Private describes a lower eyelid lift in which the incision is made inside the lower eyelid or below the eyelashes, allowing the surgeon to remove or reposition excess fat, with support for the muscles and tendons added if needed. BAAPS says skin tightening can be produced by the use of energy transfer devices (such as plasma, laser or radiofrequency), which is a separate approach from removing fat.

The NHS says that if swollen eyelids are caused by something like allergy or blepharitis, treatment is different, and it suggests asking a pharmacist what you can do to treat common eyelid problems yourself and whether you need to see an optician or GP.

The UK clinical sources do not describe a home treatment that removes age-related eye bags, because the cause is structural. What you can do depends on the cause of any swelling.

For puffiness caused by allergic conjunctivitis, Moorfields says to avoid rubbing your eyes because it will make the symptoms worse, and that a cold compress may help reduce eyelid swelling. For sticky or swollen eyelids from other common causes, the NHS recommends asking a pharmacist about cleaning solutions and other options.

Because swelling can have several causes, the NHS says not to self-diagnose, and to see a pharmacist, GP or optician.

Leeds Teaching Hospitals says blepharoplasty is usually performed on a day care basis and can take 1 to 3 hours, depending on whether all four lids or just two are done. Moorfields Private says eyelid surgery generally takes between 45 minutes and two and a half hours and is performed under local anaesthetic with sedation for shorter procedures or general anaesthetic for longer ones.

Afterwards, Leeds says swelling, bruising and blurry vision are common and stitches are removed 5 to 7 days after surgery, except where self-dissolving sutures are used. Moorfields Private says you can expect to return to your normal routine within a day or two, although bruising may be visible for up to a fortnight, and that you will not be able to drive for a few days.

Leeds notes that although the puffiness of the fat pockets may not return, normal wrinkling and ageing of the eye area will continue.

Leeds Teaching Hospitals lists possible complications as bleeding and swelling, delayed healing, scarring, infection, drooping of the upper eyelid or retraction of the lower eyelid, asymmetry, double vision and dry eye. It says that, rarely, a bleed tracking behind the eyeball (retrobulbar bleed) can threaten sight.

Cambridge University Hospitals says swelling on the surface of the eye (chemosis) is typically associated with lower eyelid blepharoplasty and could last for several weeks or months, and that the risk of loss of vision is extremely rare, in the region of 1 in 22,000 per side. Dry, gritty eyes are more likely if you already had dry eyes.

BAAPS advises stopping smoking or vaping with nicotine 6 weeks before surgery, because it reduces blood flow to the tissues and is associated with poorer healing. Smokers are known to have healing problems, according to Leeds.

Cambridge University Hospitals says the NHS will only allow removal of excess upper eyelid skin if it impairs vision, confirmed with a visual field test, and that surgery for cosmetic reasons, including lower lid blepharoplasty, is not funded by the NHS. Leeds says that when blepharoplasty is performed to improve vision, rather than for cosmetic reasons only, it may be done under the NHS service.

Lower lid surgery for bags is therefore usually arranged privately. The NHS cosmetic procedures guide points to Save Face and the British Association of Aesthetic Plastic Surgeons for information on choosing a provider. Moorfields Private says your surgeon will assess you for factors that increase risk, such as diabetes, thyroid eye disease and dry eyes, and a first appointment includes a full medical history and detailed examination.

The NHS says many eyelid problems are not serious, but to see a GP if you are worried about an eyelid problem, your eyelid symptoms are not improving or are lasting a long time, or you have yellow lumps or patches around your eyes.

The NHS says to ask for an urgent GP or optician appointment, or get help from NHS 111, if your swollen eyelid is red, hot, painful, tender or blistered, your eyelid droops suddenly, you cannot open your eye or keep it open, the pain is in your eye rather than your eyelid, the white of your eye is very red, you are sensitive to light, your eyesight changes, you have a very high temperature or feel generally unwell, or you think it is an allergic reaction.