Floppy Eyelid Syndrome

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.

Roy Frederick Hampton, Fraunfelder Frederick W, Fraunfelder Frederick T, Tindall Renee, Jensvold Bree. Roy and Fraunfelder’s Current Ocular Therapy Sixth Edition. Saunders Elsevier 2008. P 444- 446.

Jackson Timothy L. Moorfields Manual of Ophthalmology. Mosby Elsevier 2008.

Roy Frederick Hampton, Tindall Renee. Master Techniques in Ophthalmic Surgery Second Edition. Jaypee Brothers Medical Publishers (P) Ltd 2015. P 346- 351.

Roy Frederick Hampton. Ocular Syndromes and Systemic Diseases Fifth Edition. Jaypee Brothers Medical Publishers (P) Ltd 2014. P 287- 288.

Holland Edward J, Mannis Mark J, Lee W. Barry. Ocular Surface Diseases- Cornea, Conjunctiva, and Tear Film. Elsevier Saunders 2013. P 36.

Mannis Mark J, Holland Edward J. Cornea- Fundamentals, Diagnosis and Management Fourth Edition. Elsevier 2017. P 306- 308.

Chern Kenneth C, Zegans Michael E. Ophthalmology Review Manual. Lippincott Williams & Wilkins 2000. P 23.

Agarwal Amar, Jacob Soosan. Color Atlas of Ophthalmology- The Quick- Reference Manual for Diagnosis and Treatment Second Edition. Thieme Medical Publishers, Inc. 2010. P 44- 45.

Bowling Brad, Kanski's Clinical Ophthalmology- A Systematic Approach. Eighth Edition. Elsevier, 2016. P 52- 55.

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

• Irritation of eyes.
• Matting or discharge from the eyes.
• Blepharoptosis and dermatochalasis may result from repetitive mechanical trauma due to lid-to-pillow contact.
• Punctate corneal keratopathy.
• Infectious keratitis.
• Bilateral corneal neovascularisation.
• Corneal ulceration.
• Corneal scarring.
• Recurrent corneal erosion syndrome.
• Filamentary keratitis.

There may be ectropion of the lower eyelid as well.

Various causes have been implicated as aetiological factors.

• Decrease in the amount of elastin: Studies have shown significant decrease in the amount of elastin within the tarsal plate and eyelid skin. It is probably induced by repeated mechanical stress, associated with eye rubbing or by sleeping habits. Patients with FES consistently sleep face down with their eyes pressed against the pillow. The disorder may be bilateral or unilateral, but there is close correlation of the eye with the side on which the patient preferentially sleeps.
• Poor contact of lax eyelid with the globe: Poor contact of lax eyelid with the globe in conjunction with abnormalities of meibomian glands and tear films, may contribute to the syndrome. Tear film abnormalities are characterised by lipid deficiency with consequent rapid rate of evaporation of tears.
• Obstructive sleep apnoea (OSA): Obstructive sleep apnoea may contribute to local eyelid ischaemia which may play a role in development of FES. This ischaemia may be exacerbated by hypoventilation of OSA. These patients demonstrate partial or complete collapse of the airway during inspiration.

Diagnosis depends upon

• The identification of a lax, distensible tarsal plate.
• Papillary changes of the conjunctiva.
• Ready eversion of tarsal plates in classical cases on superior traction of the eyebrow.

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.

Atopic keratoconjunctivitis.

Giant papillary conjunctivitis.

Superior limbic keratoconjunctivitis.

Dermatochalasis.

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

• Mechanical shielding: Mechanical shielding of eyelids with tape may prevent eversion.
• Sleep mask: Sleep mask help in interrupting lid-pillow contact during sleep.
• Topical lubrication: Symptomatic topical lubrication helps in alleviating irritation and discharge from eyes.
• Avoid rubbing: Patients should avoid rubbing their eyes.

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.

• Horizontal shortening of eyelids: Horizontal shortening of eyelids may be tried. There is tendency for the lids to restretch and evert.
• Lateral canthopexy: Lateral canthopexy may be more effective form of shortening eyelid.
• Tarsorrhaphy: Patients who fail to respond to horizontal tightening may require tarsorrhaphy to prevent eyelid eversion.

During horizontal tightening, ptosis repair, eyelash repositioning and blepharoplasty may also be performed.