FLOPPY EYELID SYNDROME

Signs and Symptoms

Loose lid and poor lid/globe congruity.

Loose lid upon eversion.

Floppy eyelid syndrome (FES) is a relatively uncommon ocular condition characterized by flaccid, easily everted upper lids. It is usually seen in overweight, middle-aged males, although it may occasionally be encountered in women and non-obese individuals. A fair percentage of these patients also suffer from obstructive sleep apnea (OSA), a disorder marked by partial collapse of the pharynx during inspiration, resulting in loud snoring and gasping for air.^1­3

Symptoms generally consist of ocular injection, irritation, itching and stringy mucous discharge, particularly upon awakening. The symptoms may appear unilaterally or asymmetrically. Patients with OSA may also complain of erratic sleep patterns, chronic somnolence and morning headaches.

Examination of patients with FES typically reveals chronic papillary conjunctivitis with mild to moderate bulbar hyperemia, often lateralizing to the patient's habitual sleeping side (i.e., if they sleep on their left side, the presentation is more evident O.S.). Punctate corneal epitheliopathy and mucous strands in the tear film and fornices may also be apparent. The lids themselves routinely display pseudoptosis and an odd "rubbery" consistency. Eversion of the upper lids can be accomplished with minimal manipulation; in fact, it may occur spontaneously during normal ocular examination. Past ocular history may include meibomian gland dysfunction, hordeola or chalazia, keratoconus, and seasonal allergic conjunctivitis.

Pathophysiology

The etiology of FES is not thoroughly understood. Research has demonstrated that tarsal elastin is significantly diminished in these patients, such that the tarsal plate of the eyelid no longer displays its customary rigidity.⁴ One study suggests that individuals with FES may actually have underlying genetic collagen or elastin abnormalities.⁵

The precise mechanism of this disorder also remains disputed. The most widely held theory suggests that, because of the lid laxity and tendency of these patients to lie on their sides or in a "face-down" position, spontaneous lid eversion occurs during sleep. This results in mechanical abrasion of the ocular surface. Others have suggested that the underlying mechanism is simply poor apposition of the upper eyelid to the globe, instigating an inadequate tear distribution and subsequent desiccation of the ocular surface.

Management

In the majority of cases, diagnosis is made by the classic appearance and effortless or spontaneous eversion of the eyelids. There are few ancillary tests to consider beyond the normal ocular evaluation, though vital dye staining (e.g., sodium fluorescein, rose bengal and/or lissamine green) may help to assess the severity of any associated keratopathy.

Treatment for FES consists primarily of lubricating the ocular surface and safeguarding the eye from nocturnal damage. Isotonic artificial tears, used liberally throughout the day, help to eliminate mucous debris and promote corneal healing. In cases of moderate or profound epitheliopathy, consider more viscous lubricants such as Systane or Refresh Liquigel on a qid basis. At bedtime, the patient should instill either a bland ophthalmic ointment (e.g. Tears Naturale P.M.) or mild antibiotic ointment and apply a protective eye shield, or simply tape the lids in a closed position. Severe, recalcitrant cases that do not respond to primary therapy may require surgical intervention. Most commonly, this involves a lateral eyelid tightening procedure at the lateral canthus, or a horizontal lid shortening procedure by full-thickness resection of the lateral one-third of the lid margin.⁶ Lateral tarsorrhaphy has been suggested for noncompliant patients with severe disease.⁷

As important as managing the ocular sequelae of FES is addressing the associated problem of obstructive sleep apnea. OSA is a potentially fatal condition that has been linked to pulmonary hypertension, congestive heart failure and cardiac arrhythmia. Weight loss and consultation with a sleep physician for appropriate studies are highly recommended, considering the significant comorbidities of both obesity and OSA. At least one study has demonstrated notable improvement of FES when OSA is properly addressed.⁸

Clinical Pearls

• Many patients with FES manifest attendant blepharitis, particularly meibomian gland dysfunction. Rosacea has also been found in association with both FES and OSA. Strongly consider a trial of oral doxycycline 100mg bid for six to 12 weeks.
• When interviewing patients with FES, always remember to inquire about prominent snoring or gasping episodes during sleep. In this regard, realize that a spouse or family member may actually prove to be a more reliable resource than the patient! Any such findings consistent with OSA warrant consultation with a sleep physician, otolaryngologist or pulmonologist.

Other reports in this section

• Floppy Eyelid Syndrome
• Herpes Simplex Blepharitis
• Dacryocystitis
• Dermatochalasis & Blepharochalasis
• Xanthelasma