Floppy eyelid syndrome (FES) is frequently an unrecognised cause of chronic, non-infectious unilateral or bilateral papillary conjunctivitis. It is characterised by loose floppy eyelids associated with punctate epithelial keratopathy (PEK), ptosis of lateral eyelashes and typical conjunctival changes.
Floppy eyelid syndrome was described initially by Culbertson and Ostler (1981). Prior to this, it was not recognised as a specific entity. The syndrome was seen in overweight male patients with floppy, rubbery, and easily everted upper eyelids. It may be associated with a variable chronic papillary conjunctivitis of the upper palpebral conjunctiva.
It affects patients of both sexes ranging in age from two to eighty years, but it affects more commonly middle-aged obese males. The floppiness of the eyelids is due to laxity of the tarsus. Decrease in tarsal elastin contributes to the laxity of eyelids.
In addition to involvement of anterior segment, FES may also be associated with glaucoma and papilloedema due to raised intracranial pressure.
A number of systemic diseases may be associated with FES, such as diabetes mellitus, hyperthyroidism and hypertension. These diseases may correlate better with preponderance of patients with obesity in this disorder. Obstructive sleep apnoea appears to be a particular risk, especially for obese males with FES.
References
Yanoff Myron, Sassani Joseph W. Ocular Pathology Seventh Edition. Elsevier Saunders 2015. P 155.
Jackson Timothy L. Moorfields Manual of Ophthalmology. Mosby Elsevier 2008.
http://emedicine.medscape.com/article/1212978-overview
http://eyewiki.aao.org/Floppy_eyelid_syndrome
http://bjo.bmj.com/content/bjophthalmol/67/4/264.full.pdf
Iyengar SS, Khan JA. Quantifying upper eyelid laxity in symptomatic floppy eyelid syndrome by measurement of anterior eyelid distraction. Ophthal Plast Reconstr Surg 2007; 23(3): 255.
Culbertson WW, Ostler HB. The floppy eyelid syndrome. Am J Ophthalmol 1981; 92: 568- 575.
The syndrome is characterised by a triad of diffuse papillary conjunctivitis, a loose upper eyelid which everts readily (positive lid eversion sign), and a soft rubbery tarsus which may be folded on itself. It may be associated with lash ptosis, which usually involves lateral lashes of the upper eyelid.
Untreated FES may be associated with
There may be ectropion of the lower eyelid as well.
Various causes have been implicated as aetiological factors.
Diagnosis depends upon
Upper eyelid distraction of 14 mm or more is consistent with the diagnosis, as described by Iyengar (2007).
Differential diagnosis
It may be distinguished from conditions like
Allergic conjunctivitis.
Ectropion.
Giant papillary conjunctivitis.
Management should be carried out under medical supervision.
Treatment is directed toward interrupting the eversion of the tarsus during sleep.
Medical therapy:
It consists of
Surgical therapy:
Surgical procedures to tighten the eyelids may not be successful, unless the face-down sleeping position is resolved. As majority of patients with FES will have OSA, its resolution along with supine sleep position is important.
During horizontal tightening, ptosis repair, eyelash repositioning and blepharoplasty may also be performed.