Floppy Eyelid Syndrome
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Overview
Floppy Eyelid Syndrome (FES) is an eye disorder that causes the upper eyelids to droop and turn outward. It is a rare condition marked by loose upper eyelids that can easily be turned inside out. FES is most commonly seen in overweight, middle-aged males who sometimes suffer from sleep apnea. Symptoms include irritation, itching, and mucus discharge either unilaterally or bilaterally. Treatment for this condition includes artificial tears to reduce irritation and antibiotics if an infection is present. In some cases, either tape or an eye shield may help keep the eyelids closed while sleeping. This remedy may also prevent lid eversion and keep the eyes from becoming dry.
Patients with FES often have issues with papillary conjunctivitis and mild to moderate bulbar hyperemia. This is usually more severe on the patient’s habitual sleeping side. A patient’s tear film can be marked by corneal epitheliopathy and heavy mucus strands, and the eyelids show pseudoptosis and a strange rubbery consistency. In patients with FES, turning the upper lids inside out can be accomplished with minimal manipulation and can even occur spontaneously. These patients may develop blepharitis and meibomian gland dysfunction. Rosacea is also linked to FES in patients with sleep apnea and for these individuals oral doxycycline may help reduce symptoms.
Pathophysiology
Tarsal elastin is significantly diminished in FES patients as their tarsal plates no longer exhibit their usual rigidity. Some studies suggest that FES patients may have genetic collagen or elastin abnormalities. Another theory posits that due to lid laxity and the tendency to sleep on one side, spontaneous lid eversion occurs during sleep, resulting in mechanical abrasion of the ocular surface. Regardless, the pathophysiology is not well understood.
Management
At Idaho Eyelid and Facial Plastic Surgery, diagnosis is typically made by the appearance and the effortless or spontaneous eversion of the eyelids. There are few ancillary tests to consider beyond the normal ocular evaluation, though vital dye staining may help assess the severity of any associated keratopathy. Treatment for FES involves lubricating the ocular surface and protecting the eye safe from nocturnal damage. Artificial tears help eliminate mucus debris and promote corneal healing. In cases of epitheliopathy, more viscous lubricants are recommended. At night, FES patients should use either an ophthalmic ointment or a mild antibiotic ointment and apply a protective eye shield or tape. Patients who do not respond to primary therapy may require surgical intervention involving a lateral eyelid tightening procedure at the lateral canthus.
When taking the medical history at Idaho Eyelid and Facial Plastic Surgery, we will inquire about prominent snoring or gasping episodes during sleep as this often coincides with FES. It can be a dangerous condition. Idaho Eyelid and Facial Plastic Surgery can refer you to sleep clinics as needed.
References
McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg 1997;13(2):98-114. Mojon DS, Goldblum D, Fleischhauer J, et al. Eyelid, conjunctival, and corneal findings in sleep apnea syndrome. Ophthalmology 1999;106(6):1182-5. Robert PY, Adenis JP, Tapie P, et al. Eyelid hyperlaxity and obstructive sleep apnea (O.S.A.) syndrome. Eur J Ophthalmol 1997;7(3):211-5. Netland PA, Sugrue SP, Albert DM, et al. Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology 1994; 10(1)1:174-81. Lee WJ, Kim JC, Shyn KH. Clinical evaluation of corneal diseases associated with floppy eyelid syndrome. Kor J Ophthalmol 1996;10(2):116-21. Periman LM, Sires BS. Floppy eyelid syndrome: A modified surgical technique. Ophthal Plast Reconstr Surg 2002;18(5):370-2. Bouchard CS. Lateral tarsorrhaphy for a noncompliant patient with floppy eyelid syndrome. Am J Ophthalmol 1992;114(3):367-9. McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea. Clin Experiment Ophthalmol 2000;28(2):125-6.
