Inverse Bell's phenomenon following eyelid surgery: a case series and comprehensive review

Inverse Bell's phenomenon (IBP) is a rare but clinically significant complication of eyelid surgery, characterized by paradoxical downward deviation of the globe during attempted eyelid closure. This study presents a retrospective case series of four patients who developed IBP within three months after upper eyelid surgery at a tertiary oculoplastic center (2018-2024) together with a review of the literature. Presentations ranged from transient IBP that resolved spontaneously to persistent cases associated with lagophthalmos or ocular surface disease. Two patients regained a normal Bell's reflex after conservative or surgical management, whereas two developed chronic IBP despite intervention. Literature review indicates that most cases are transient, although persistent IBP may result from scarring, fibrosis, or neuromuscular disruption. Careful preoperative assessment of Bell's reflex, close postoperative monitoring, and early individualized management are essential. While most cases resolve without sequelae, persistent IBP may necessitate surgical intervention and carries a risk of long-term ocular surface morbidity.