Floppy eyelid syndrome (FES) was initially described by Culbertson and Ostler in 1981.[1] It had not been recognized as a specific entity prior to this. The syndrome was seen in overweight male patients with floppy, rubbery, and easily everted upper eyelids associated with a variable chronic papillary conjunctivitis of the upper palpebral conjunctiva.
FES, because its symptoms are common to other disease processes, often is not diagnosed at the onset of symptoms. Several unsuccessful trials of artificial tears, vasoconstrictors, topical steroids, nonsteroidal anti-inflammatory drops, or antibiotics may already have taken place before the correct diagnosis is made. Although FES has been reported in nonobese patients, it is seen more frequently in patients who are obese. The condition often is associated with obstructive sleep apnea (OSA).[2, 3, 4, 5, 6, 7]
Patients with OSA experience episodic apnea and hypopnea as a consequence of intermittent obstruction of the upper airway. When these patients sleep on their backs, a collapse of the pharynx occurs during inspiration, resulting in loud snoring and eventual apnea, which causes the patient to awaken. OSA eventually can lead to systemic or pulmonary hypertension, congestive heart failure, and cardiac arrhythmia. OSA is associated with other serious ocular disorders, such as glaucoma, ischemic optic neuropathy, and papilledema secondary to increased intracranial pressure. Treatment of OSA can reduce intracranial pressure and secondary papilledema.
Patients with FES usually present with a long history of unilateral or bilateral ocular irritation and discharge with either a preexisting diagnosis of OSA or a history of snoring.
Although tarsal collagen appears normal in patients with FES, several histopathologic studies using special stains, immunohistochemistry, and electron microscopy have demonstrated a significant decrease in tarsal elastin.[8, 9, 10] The rubbery consistency and laxity of the tarsus may be related to the decrease in elastin. Eyelid laxity allows upper eyelid eversion on inadvertently rubbing the eye or lateral stretching of the lid through contact with a pillow during sleep, resulting in mechanical irritation and inflammation of the conjunctiva.
Light microscopy of surgical specimens has sometimes revealed Demodex brevis infestation.[11] The Demodex mite destroys the meibomian glands, resulting in tear film abnormalities, increased tear evaporation, and gradual atrophy of the tarsus.
Patients who sleep on one side more than the other side tend to have more severe changes on that side. This finding suggests mechanical injury as the primary cause of the papillary conjunctivitis. In many cases of FES, there is a history of loud snoring or a diagnosis of OSA, which requires the patient to sleep on one side or in a prone position with the face in the pillow. Use of an eye shield to protect the eyelids during sleep often can improve the patient’s signs and symptoms.
FES has been associated with keratoconus, which also suggests mechanical irritation from eye rubbing as a contributing factor.[12] Others have postulated that the cause of the chronic conjunctivitis is poor apposition of the lax upper eyelid to the globe with inadequate spreading of the tear film.[13] This condition leads to corneal and conjunctival compromise, rather than direct mechanical irritation. Meibomian gland dysfunction and atrophy can be found in association with FES.[14]
FES is uncommon but underrecognized. It is most commonly diagnosed among middle-aged patients (40-50 years), though it has been reported in patients aged 25-80 years.[13] The incidence of FES is slightly higher in men than in women.[12, 13] Although most reported cases have involved white patients, there is probably no racial predilection.
A medical and surgical approach to managing FES is most often successful in alleviating the patient’s symptoms.
OSA is a potentially fatal disorder. Frequent episodes of apnea and hypopnea can lead to systemic and pulmonary hypertension and, ultimately, congestive cardiomyopathy together with cardiac arrhythmia risk. Patients with OSA may complain of morning headaches and daytime somnolence, which may result in poor work performance and an increased risk of automobile accidents.[15]
Corneal erosions secondary to nocturnal eyelid eversion can result in corneal ulceration and scarring that can lead to permanent decreased vision. Chronic conjunctivitis, punctate keratopathy, and corneal neovascularization may result in contact lens intolerance.
External ophthalmic examination typically reveals the following:
Lax upper eyelid that is easily everted when pulled superiorly toward the eyebrow (see the first image below)
Soft and rubbery tarsal plate that can be folded upon itself
Laxity that can be quantified through measurement of anterior eyelid distraction[16]
Atrophic tarsal plate
Stringy, mucoid conjunctival discharge
Punctate corneal epitheliopathy and mucous strands in the tear film and fornices (possibly)
Eyelash ptosis (see the second image below) with loss of lash parallelism (ie, lashes point downward toward the cornea and curve in different directions)[8]
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Floppy eyelid syndrome. Lax, rubbery upper eyelid is easily everted as it is pulled up toward eyebrow. Conjunctival hypertrophy and inflammation are p....
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Floppy eyelid syndrome. Eyelash ptosis in patient with laxity of upper eyelid.
Periorbital involutional changes that may be noted are as follows:
Brow ptosis
Eyelid dermatochalasis
Blepharoptosis
Attenuation or dehiscence of the lateral canthal tendon
Lacrimal gland prolapse
Involutional enophthalmos
Lagophthalmos
Slit-lamp examination commonly demonstrates the following:
Lash debris
Superior papillary tarsal conjunctival hypertrophy
Superior bulbar conjunctival injection
Punctate fluorescein staining of the superior cornea and conjunctiva
Areas of devitalized epithelium and filamentary conjunctivitis with rose bengal or lissamin green stain
Superficial corneal pannus at the superior limbus
Paracentral thinning of the cornea, consistent with keratoconus
More conservative medical care often proves inadequate in relieving symptoms of floppy eyelid syndrome (FES). In many cases, surgical intervention is required, usually involving the tightening of the lax upper eyelid, which can be achieved in a number of ways.
Floppy eyelid syndrome is usually treated on an outpatient basis. Patients who are obese should be encouraged to lose weight.
Topical application of a lubricating or antibiotic ophthalmic ointment in the affected eye is indicated for mild corneal or conjunctival abnormalities. Erythromycin ophthalmic may be applied 2-4 times daily for superior punctate keratitis. (See Medication.) Lubricating ophthalmic ointment may be applied at bedtime.
If meibomian gland dysfunction is suspected, trial of an oral tetracycline (eg, such as doxycycline 100 mg once or twice daily for 6-12 wk) may be appropriate.
In addition, the patient should be instructed to tape the eyelids closed and wear an eye shield while asleep to protect the conjunctiva and the eye from rubbing on the pillow.
Upper and lower eyelids can be tightened at the lateral canthus by using a standard lateral tarsal strip procedure.[18]
Horizontal shortening of the lateral upper eyelid can be achieved by performing a full-thickness resection of the lateral one fourth to one third of the eyelid margin.[19, 20] This can be accomplished by means of a vertical full-thickness resection up to an eyelid crease incision. Ptosis repair or blepharoplasty can be performed at the same time. The disparity in skin length can be managed with a vertical Burow triangle directed toward the brow at the lateral extent of the eyelid crease incision.
A modified curvilinear back-tapered full-thickness resection with an advancement flap at the lateral upper eyelid has also been described.[21]
In cases with more medial laxity, horizontal shortening of the medial upper eyelid can be achieved by performing a laterally displaced pentagonal full-thickness resection in the medial one third of the eyelid, lateral to the superior punctum.[22] Any brow ptosis, dermatochalasis, blepharoptosis, or ectropion can be repaired at the same time.
In repairing ptosis of a lax upper eyelid, the eyelid often must be tightened to achieve the desired contour.
Complications of surgical treatment of FES include the following:
Patients treated for FES should be observed every 3-7 days initially until any keratitis is resolved; after the first week, they may be observed every 2-6 weeks, as necessary.
Antibiotic ophthalmic ointment (eg, erythromycin) is prescribed postoperatively 2-4 times a day along sutures and in the eye for 1 week. (See Medication.) Lubricating ophthalmic ointment in the eye at bedtime can be continued, as needed.
Patients with should be encouraged to refrain from sleeping with the face in the pillow, to avoid rubbing the eyes, and to lose weight if obese. Special shields or a mask may have to be fitted to shield the eye from mechanical irritation.
Clinical Context:
Erythromycin is indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Clinical Context:
This ophthalmic macrolide antibiotic is indicated for bacterial conjunctivitis caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Clinical Context:
Doxycycline inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Clinical Context:
Minocycline is a member of the tetracycline class of antimicrobial agents. It is a broad-spectrum agent that inhibits susceptible organisms by blocking their protein synthesis.
Clinical Context:
Artificial tears are used to increase lubrication of the eye. Nonpreserved artificial tears are recommended for use. Tears should be applied liberally throughout the day, and, if necessary, a lubricating ointment may be used at night. This ointment may contain an antibiotic preparation.
Lubricants act as humectants in the eye. The ideal artificial lubricant should be preservative-free; contain potassium, bicarbonate, and other electrolytes; and have a polymeric system to increase its retention time. Lubricating drops are used to reduce morbidity and to prevent complications. Lubricating ointments prevent complications from dry eyes. Ocular inserts reduce symptoms resulting from moderate-to-severe dry eye syndromes.
Mark Ventocilla, OD, FAAO, Adjunct Clinical Professor, Michigan College of Optometry; Editor, American Optometric Association Ocular Surface Society Newsletter; Chief Executive Officer, Elder Eye Care Group, PLC; Chief Executive Officer, Mark Ventocilla, OD, Inc; President, California Eye Wear, Oakwood Optical
Disclosure: Nothing to disclose.
Coauthor(s)
Andrew A Dahl, MD, FACS, Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Disclosure: Nothing to disclose.
Acknowledgements
Sean M Blaydon, MD, FACS Fellowship Program Director, Texas Oculoplastic Consultants
Sean M Blaydon, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, International College of Surgeons US Section, Pan-American Association of Ophthalmology, Pan-Pacific Surgical Association, and Texas Medical Association
Disclosure: Nothing to disclose.
Jorge G Camara, MD Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Floppy eyelid syndrome. Lax, rubbery upper eyelid is easily everted as it is pulled up toward eyebrow. Conjunctival hypertrophy and inflammation are present, in addition to mucoid discharge.
Floppy eyelid syndrome. Eyelash ptosis in patient with laxity of upper eyelid.
Floppy eyelid syndrome. Lax, rubbery upper eyelid is easily everted as it is pulled up toward eyebrow. Conjunctival hypertrophy and inflammation are present, in addition to mucoid discharge.
Floppy eyelid syndrome. Eyelash ptosis in patient with laxity of upper eyelid.
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