Teaching NeuroImages: Floppy eyelids in obstructive sleep apnea syndrome

A 52-year-old man presented with a 2-year history of snoring, excessive daytime somnolence, and discomfort and redness in the eyes. The eyes showed features of floppy eyelid syndrome: rubbery, floppy, easily everted eyelids and papillary conjunctivitis^1,2 (figure 1). Polysomnography revealed severe obstructive sleep apnea syndrome (OSAS) with apnea-hypopnea index (AHI) of 70.8/hour (figure 2). He was treated with continuous positive airway pressure therapy, resulting in improvement of daytime somnolence and eye symptoms.

Figure 1. Features of floppy eyelid syndrome.

(A) Minimal upward traction showing abnormal eversion of the eyelids, exposing the underlying tarsal conjunctiva. Papillary conjunctivitis was apparent (insert: comparison with a normal eye). (B) Mild ptosis with downward pointing eyelashes seen at the neutral position.

Figure 2. Polysomnography.

The hypnogram shows disruption of normal sleep cycle (uppermost panel) with frequent arousals (green bars in second panel from top); frequent apneic (green bars) and hypopneic episodes (pink bars), with an apnea-hypopnea Index of 70.8/hour (third panel from top); desaturation of blood oxygen level (lowermost panel).

Although the prevalence of floppy eyelid syndrome in patients with OSAS is relatively low (4.5%–5.0%), OSAS is seen in 96%–100% of patients with floppy eyelid syndrome,² making it an important and easy to detect bedside eye sign for OSAS.

AUTHOR CONTRIBUTIONS

Dr. Das: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data. Dr. Radhakrishnan: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, acquisition of data.