Floppy eyelid syndrome

A 52-year-old man presented with redness and irritation of the left eye. He had tried using artificial tear drops and gels without much benefit. On examination, the patient had redundant, wrinkled eyelid skin bilaterally with a greater amount on the affected side (Figure 1A). Ptosis of the left upper eyelid was evident, and the upper eyelashes were inverted. These lashes were in contact with the cornea, which showed chronic inflammatory changes. Diffuse, punctate epithelial defects were evident after fluorescein staining of the cornea. Slit-lamp examination showed papillary conjunctivitis. The left upper eyelid was easily distracted and everted (Figure 1B). The findings were characteristic of floppy eyelid syndrome.

Figure 1:

(A) Redundant, wrinkled eyelid skin, particularly of the left eye, in a 52-year-old man with floppy eyelid syndrome. Ptosis of the upper eyelid is evident, and the upper eyelashes are inverted. (B) Superior distraction of the upper eyelid without eversion, showing extreme laxity, folds in the usually firm tarsal plate (*) and diffuse papillary conjunctivitis involving the bulbar and palpebral conjunctiva.

Floppy eyelid syndrome is observed most often in men who are obese (body mass index ≥ 30). There are no reliable prevalence data, and no other risk groups have been identified. The precise pathophysiology remains undefined, but histopathologic studies have shown depleted levels of elastin within the tarsal plate of the eyelid, in the skin of the eyelid and adjacent to the lash roots.¹ There is an association with obstructive sleep apnea, which is believed to be an epiphenomenon.² Although there is no proven causal link, it is important to screen for symptoms of sleep apnea in patients with floppy eyelid syndrome because the estimated prevalence is 21%–100%.²

Shielding the eye while sleeping can prevent eversion of the eyelid from contact with a pillow and eliminate direct abrasion. Patients with obstructive sleep apnea who use a continuous positive airway pressure device often benefit from the imposed supine sleep position, which prevents eyelid–pillow contact.

Obstructive sleep apnea was diagnosed previously in this patient, but he could not tolerate wearing a continuous positive airway pressure device while sleeping. A horizontal tightening procedure was performed on the upper and lower eyelids, which alleviated his symptoms.

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