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Ophthalmology > LID
Floppy Eyelid Syndrome
Article Last Updated: Jun 1, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Sean M Blaydon, MD, FACS, Consulting Staff, Department of Ophthalmology, Texas Oculoplastics Consultants
Sean M Blaydon is a member of the following medical societies: American Academy of Ophthalmology, 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-Pacific Surgical Association, and Texas Medical Association
Editors: Jorge G Camara, MD, Chairman, Department of Ophthalmology and Otorhinolaryngology, Director of Fellowship Training Program, St Francis Medical Center; Associate Professor, Department of Surgery, University of Hawaii School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
FES, lax eyelid syndrome, obstructive sleep apnea, OSA
Background
Floppy eyelid syndrome (FES) was initially described by Culbertson and Ostler in 1981. It was seen in overweight male patients with floppy, rubbery, and easily everted upper eyelids associated with chronic papillary conjunctivitis of the upper palpebral conjunctiva.
FES often is unrecognized. Unsuccessful trials of artificial tears, vasoconstrictors, or topical steroids and antibiotics have already occurred 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).
Patients with OSA experience episodic apnea and hypopnea due to 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.
Pathophysiology
Although tarsal collagen appears normal in patients with FES, several histopathologic studies have demonstrated a significant decrease in tarsal elastin using special stains, immunohistochemistry, and electron microscopy.
- The rubbery consistency and laxity of the tarsus may be related to the decrease in elastin.
- Eyelid laxity allows upper eyelid eversion on contact with a pillow during sleep, resulting in mechanical irritation and inflammation of the conjunctiva.
- 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, requiring the patient to sleep on their side or in a prone position with their 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.
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. 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.
- Light microscopy of surgical specimens has revealed Demodex brevis infestation.
- The Demodex mite destroys the meibomian glands, resulting in tear film abnormalities, increased tear evaporation, and a gradual atrophy of the tarsus.
Frequency
United States
Uncommon but underrecognized
Mortality/Morbidity
- OSA is a potentially fatal disorder. Frequent episodes of apnea and hypopnea can lead to systemic and pulmonary hypertension, and ultimately congestive cardiomyopathy. Patients with OSA may complain of morning headaches and daytime somnolence, resulting in poor work performance and an increased risk of automobile accidents.
- 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 can result in contact lens intolerance.
Race
Although most reported cases have involved Caucasian patients, there is probably no race predilection.
Sex
Incidence of FES is slightly more prevalent in men than in women.
Age
FES most commonly is diagnosed among middle-aged patients (40-50 years). Previous reports have noted FES among patients aged 25-80 years.
History
- Presenting symptoms
- Unilateral or bilateral chronic eye irritation and burning
- Tearing
- Ropy, mucoid discharge; usually worse in the morning
- Decreased vision, if there is an associated keratopathy
- Daytime somnolence
- Morning headaches
- Sleep history
- Usually sleeps on side or face down in pillow
- Frequent episodes of waking up during the night
- Past ocular history
- Chalazia or hordeola
- Keratoconus
- Contact lens use
- Seasonal symptoms
- Past medical history
- Acne rosacea
- Psoriasis
- Hypertension
- Congestive heart failure
- Obstructive sleep apnea
Physical
- Complete ophthalmic examination
- External examination
- Lax upper eyelid that is everted easily when pulled superiorly toward eyebrow
- Soft and rubbery tarsal plate that can be folded upon itself
- Tarsal plate may appear atrophic
- Stringy, mucoid conjunctival discharge
- Eyelash ptosis with loss of lash parallelism (ie, lashes lie in downward direction toward cornea and curve in different directions)
- Periorbital involutional changes
- Brow ptosis
- Eyelid dermatochalasis
- Blepharoptosis
- Attenuation or dehiscence of the lateral canthal tendon
- Lacrimal gland prolapse
- Involutional enophthalmos
- Lagophthalmos
- Slit lamp examination
- Lash debris (scurf)
- Superior papillary tarsal conjunctival hypertrophy
- Superior bulbar conjunctival injection
- Punctate fluorescein staining of superior cornea and conjunctiva
- Rose bengal stain may reveal areas of devitalized epithelium and filamentary conjunctivitis
- Superficial corneal pannus at superior limbus
- Paracentral thinning of cornea consistent with keratoconus
Causes
See Pathophysiology.
Blepharitis, Adult
Chalazion
Conjunctivitis, Allergic
Conjunctivitis, Giant Papillary
Contact Lens Complications
Dacryocystitis
Demodicosis
Dermatochalasis
Ectropion
Hordeolum
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Superior Limbic
Keratoconus
Ocular Rosacea
Psoriasis
Ptosis, Adult
Lab Studies
- Conjunctival scrapings
- Predominance of polymorphonuclear leukocytes (PMNs) with variable amounts of eosinophils and lymphocytes
- Papillary conjunctival hypertrophy
Other Tests
- Sleep studies - If suspect OSA, then patient should be sent for polysomnography.
- Tear break-up test (TBUT) - May be less than 10 seconds in FES, indicating tear instability (normal TBUT is 15-20 seconds)
Histologic Findings
Light microscopy of surgical specimens may reveal usual findings of chronic conjunctival inflammation; abnormalities of the meibomian glands, such as granuloma formation; and decrease in tarsal elastin.
Medical Care
- Topical lubricating or antibiotic ophthalmic ointment in affected eye for mild corneal or conjunctival abnormalities
- Erythromycin ophthalmic ointment in the eye 2-4 times a day for superior punctate keratitis (See Medication.)
- Lubricating ophthalmic ointment in the eye at bedtime
- Trial of a tetracycline, such as doxycycline 100 mg PO qd/bid, if meibomian gland dysfunction is suspected.
- Have the patient tape the eyelids closed and wear an eye shield while asleep to protect the conjunctiva and eye from rubbing on the pillow.
Surgical Care
- More conservative medical care often proves inadequate in relieving these patients' symptoms. In most cases, surgical intervention is required, usually involving the tightening of the lax upper eyelid, which can be achieved in a number of ways.
- Upper eyelid can be tightened at the lateral canthus using a standard tarsal strip procedure.
- Horizontal shortening of the lateral upper eyelid by full-thickness resection of the lateral one fourth to one third of the eyelid margin.
- This can be accomplished by vertical full-thickness resection up to an eyelid crease incision. Ptosis repair and/or blepharoplasty can be performed at the same time. The disparity in skin length can be managed by a vertical Burrows triangle toward the brow at the lateral extent of the eyelid crease incision.
- A modified curvilinear back-tapered full-thickness resection with advancement flap at the lateral upper eyelid has also been described.
- In cases with more medial laxity, a horizontal shortening of the medial upper eyelid can be performed by full-thickness resection in the medial one third of the eyelid, lateral to the superior punctum.
- Any brow ptosis, dermatochalasis, blepharoptosis, or ectropion can be repaired at the same time.
- When repairing ptosis of a lax upper eyelid, the eyelid often needs to be tightened to achieve the desired contour.
- Treatment of OSA
- Nasal continuous positive airway pressure (CPAP)
- Surgical intervention usually involves modification of the pharyngeal airway by extirpation of soft tissue (uvulopalatopharyngoplasty) with possible modification of the underlying craniofacial skeleton.
Consultations
- Oculoplastic consultation, if upper eyelid tightening and ptosis repair is required and referring physician is uncomfortable with this procedure
- Referral to internal or pulmonary medicine for evaluation and medical management of possible OSA
- Head and neck surgery consultation, if patient has failed medical management of OSA
Diet
- If obese, the patient should be encouraged to lose weight.
The goal of pharmacotherapy is to reduce morbidity and to prevent complications.
Drug Category: Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
| Drug Name | Erythromycin (E-Mycin) |
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| Description | Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections. |
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| Adult Dose | Apply 0.5-inch (1.25 cm) ribbon 2-8 times/d depending on severity of infection |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; viral, mycobacterial, fungal infections of eye; patients using steroid combinations after uncomplicated removal of a foreign body from cornea also should avoid using this product |
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| Interactions | None reported |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection; take appropriate measures if superinfection occurs |
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| Drug Name | Doxycycline (Bio-Tab, Doryx, Vibramycin) |
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| Description | Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. |
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| Adult Dose | 100 mg PO qd/bid |
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| Pediatric Dose | <8 years: Not recommended
> 8 years: 2-5 mg/kg/d in 1-2 divided doses; not to exceed 200 mg/d |
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| Contraindications | Documented hypersensitivity; severe hepatic dysfunction |
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| Interactions | Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy |
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| Pregnancy | D - Unsafe in pregnancy
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| Precautions | Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines |
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Further Inpatient Care
- FES usually is treated on an outpatient basis.
Further Outpatient Care
- Patient should be observed every 3-7 days initially until any keratitis is resolved; then, the patient can be observed every 2-6 weeks, as necessary.
In/Out Patient Meds
- Antibiotic ophthalmic ointment, such as 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.
Deterrence/Prevention
- Patients with FES should be encouraged to refrain from sleeping with their face in the pillow, to avoid rubbing their eyes, and to lose weight if obese.
- Special shields or a mask may need to be fitted to shield the eye from this mechanical irritation.
Complications
- Complications of surgery to repair FES include the following:
- Poor wound healing
- Unacceptable eyelid height or contour
Prognosis
- A medical and surgical approach to managing FES most often is successful in improving the patient's symptoms.
Patient Education
- The following items should be discussed with the patient:
- Significance of sleeping with face against the pillow
- Connection between rubbing eyes, keratoconus, and FES
- Possibility of associated OSA and the need for further tests to evaluate for this condition, if warranted
- Treatment options
Medical/Legal Pitfalls
- Patient should be evaluated for obstructive sleep apnea because this can be a fatal condition.
| Media file 1:
A patient with floppy eyelid syndrome. The lax and rubbery upper eyelid is everted easily as it is pulled up toward the eyebrow. Hypertrophy and inflammation of the conjunctiva is present, in addition to a mucoid discharge. |
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Media type: Photo
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| Media file 2:
Eyelash ptosis in a patient with laxity of the upper eyelid. |
 | View Full Size Image | |
Media type: Photo
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Floppy Eyelid Syndrome excerpt Article Last Updated: Jun 1, 2006
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