Floppy eyelid syndrome

Overview

Floppy Eyelid Syndrome (FES) is a chronic eyelid disorder characterized by unusually loose and easily everted upper eyelids. The condition is often associated with eye irritation, chronic conjunctivitis, and ocular surface damage. FES predominantly affects overweight middle-aged men and is frequently linked with obstructive sleep apnea (OSA). Patients typically experience symptoms that worsen during sleep or upon awakening due to mechanical trauma to the exposed ocular surface.

Causes

The exact cause of Floppy Eyelid Syndrome is not fully understood, but it is believed to result from abnormalities in the connective tissue of the eyelids. Factors that contribute to FES include:

• Obesity: A strong risk factor, possibly due to mechanical and hormonal effects on eyelid tissue.

• Obstructive sleep apnea (OSA): Commonly associated with FES, with shared risk factors and pathophysiology.

• Connective tissue abnormalities: Degradation of elastin and collagen in the eyelid, leading to increased laxity.

• Chronic eye rubbing: Often due to itching or irritation, which can worsen eyelid laxity.

Symptoms

Floppy Eyelid Syndrome typically presents with both ocular and eyelid-related symptoms. These may include:

• Red, irritated eyes, especially in the morning

• Chronic conjunctivitis (inflammation of the conjunctiva)

• Mucoid discharge from the eyes

• Foreign body sensation or burning eyes

• Drooping or unusually lax upper eyelids

• Spontaneous eversion of the upper eyelids during sleep

• Blurred vision due to tear film instability

• Symptoms often worse on the side a person sleeps on

Diagnosis

Diagnosis of FES is based on clinical evaluation by an ophthalmologist. Diagnostic steps may include:

• Physical examination: Eversion of the upper eyelids with minimal effort is a hallmark feature.

• Slit-lamp examination: To assess for signs of conjunctivitis, keratitis, or corneal damage.

• Tear film assessment: To evaluate for dry eye or tear film instability.

• Sleep study: Often recommended to assess for coexisting obstructive sleep apnea.

Treatment

Treatment for Floppy Eyelid Syndrome focuses on relieving symptoms, protecting the ocular surface, and addressing the underlying eyelid laxity. Common management strategies include:

• Lubricating eye drops and ointments: To reduce dryness and protect the cornea.

• Nighttime eye shields or taping: To prevent eyelid eversion during sleep.

• Antibiotic or anti-inflammatory eye drops: For managing chronic conjunctivitis or corneal involvement.

• Treatment of sleep apnea: Continuous Positive Airway Pressure (CPAP) therapy if OSA is present.

• Surgical correction: Eyelid tightening procedures (e.g., lateral tarsal strip surgery) for severe or persistent cases.

Prognosis

The prognosis for Floppy Eyelid Syndrome is generally good with appropriate treatment. Symptom control is achievable in most cases, particularly with surgical intervention for eyelid tightening. However, recurrence is possible if contributing factors such as sleep apnea or obesity are not addressed. Early diagnosis and multidisciplinary management, including ophthalmologic and sleep medicine care, are essential for optimal outcomes.