Loose lids sync sleep?

Case

A 30-year-old obese Asian-Indian male patient presented to the Oculoplasty clinic complaining of intermittent watering and irritation of both eyes for 2 years. His best-corrected visual acuity was 20/20 in both eyes. On slit-lamp biomicroscopic examination, both eyes showed meibomian gland dysfunction, conjunctival congestion, and presence of papillae in upper palpebral conjunctiva [Figure 1a]. His upper eyelids could be easily everted with distraction of about 8–10 mm [Figure 1b]. Superficial punctate keratitis was present in both the eyes. The tear meniscus height and tear film breakup time was found to be decreased. Schirmer's test was 3 mm. Rest of the anterior segment examination revealed normal findings including intraocular pressure. Fundus examination on indirect ophthalmoscopy was within normal limits. On further questioning, the patient acquiesced to feeling sleepy during the day and also his wife complained that he snores during sleep. He did not have any other systemic abnormality.

Figure 1.

(a) Slit-lamp photograph showing conjunctival congestion, and the presence of papillae in the upper palpebral conjunctiva. (b) Easily everted upper eyelids with distraction of about 8–10 mm

Questions

1. What is the diagnosis?

2. What will you do next?”

Answer

What is the diagnosis?

Floppy Eyelid Syndrome (FES)

What would you do next?

1. Refer the patient to a sleep specialist

2. Get corneal topography done

3. Prescribe lubricants

4. Advise eyelid surgery.”

Discussion

FES is characterized by symptoms of ocular irritation with easy eversion of upper eyelids associated with reactive changes in the conjunctiva and cornea. It is commonly seen in obese, middle-aged males.[1] Increased laxity of the tarsal plates can be demonstrated by increased upward excursion on vertical traction (distraction test). Other ocular associations in FES are aponeurotic ptosis, dermatochalasis, keratoconus, keratoconjunctivitis, glaucoma, eyelash ptosis, and recurrent corneal erosions.[2] Common systemic associations are obesity, hypertension, diabetes mellitus, gastroesophageal reflux disease, asthma, and chronic renal failure.[1,2]

Up to 100% of patients with FES may have obstructive sleep apnoea (OSA) and can develop multiple episodes of apneic spells during sleep.[1,2] The resultant sleep disturbance results in increased daytime somnolence, headache, and lethargy.[3] OSA is an under recognized public health concern with significant morbidity. Early detection and treatment is critical due to the increased risk of pulmonary hypertension, and cardiac arrhythmias associated with untreated cases.[3]

This patient was explained about the nature of the disease and was referred to a sleep specialist. Overnight four channel sleep study (polysomnography) revealed frequent episodes of snoring, apneas and hypopneas with oxygen desaturation. The patient was counseled regarding weight loss measures and was advised nocturnal continuous positive airway pressure therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.