Floppy eyelid syndrome

PURPOSE OF REVIEW: Although floppy eyelid syndrome causes significant ocular symptoms and morbidity, the condition is often underdiagnosed. This review will highlight diagnostic features of the condition, emphasizing recent advances in the understanding of its pathophysiology. Current therapeutic strategies and surgical techniques are discussed. RECENT FINDINGS: Current concepts regarding the underlying pathophysiology of floppy eyelid syndrome revolve around upregulation of elastin degrading enzymes and mechanical factors. Together, these forces cause instability of the eyelid scaffold, resulting in eyelid malposition and ocular symptoms. Newer surgical treatments aim to preserve tarsus to improve eyelid stability and position. SUMMARY: Floppy eyelid syndrome--an underdiagnosed condition--produces significant ocular morbidity. Symptoms range from occasional redness and irritation to corneal ulcer. Diagnosis is based on ocular signs, including easy or spontaneous eversion of the upper eyelids in conjunction with conjunctivitis and keratitis. The condition, associated with body mass index and obstructive sleep apnea, should be suspected in any obese patient with a chronic red and tearing eye. Treatment consists of supportive measures such as ocular lubrication, eyelid taping or a shield, and surgery to address horizontal laxity and redundant eyelid tissues.     

Operation of the floppy eyelid. Symptomatic cases require surgical eyelid stabilization

BACKGROUND: Floppy Eyelid is a rare condition causing chronic papillary conjunctivitis and chronic corneal disorders (superficial punctate keratitis, epithelial and stromal ulcers). It is characterized by an extremely enlarged and "floppy" upper eyelid which can be easily everted by slight elevation. Usually obese men are affected who use to sleep face down either on the right or on the left side. Pushing the eyelid against the pillow, the lid is intermittently everted at sleep. This lagophthalmus with rubbing of the exposed eye and lid structures causes all pathologic disorders. Shielding the eye at night may help temporarily. PATIENTS: We performed surgery on 7 men with symptomatic floppy eyelid in the age of 42 to 61 years. The patients had been symptomatic between 1 month and 4 years prior to the definite diagnosis. Follow-up time has been 7 months to 4.5 years. RESULTS: In all cases surgery achieved improvement. CONCLUSIONS: Cases of unclear conjunctival or corneal damage and inflammation should led consider Floppy Eyelid as a possible cause. The typical clinical findings make diagnosis easy. As complete stopping of eyelid-rubbing by changing the patient's sleeping habits is mostly not easily possible, for acute therapy of threatening damages to cornea and conjunctiva a surgical shortening of the lid is necessary which stabilizes the lid in order to avoid nightly spontaneous eversion for a long time.     

Keratoconus associated with floppy eyelid syndrome.

Floppy eyelid syndrome is a recently described entity, which characteristically involves overweight individuals. The characteristic findings are an upper lid that may be readily everted, tarsal laxity, and diffuse papillary conjunctival changes. The cause of floppy eyelid syndrome is believed to be a mechanical disorder due to the eversion of the lids while sleeping. The cause of keratoconus remains uncertain. There are strong proponents to a mechanical etiology for this disease. The authors report five cases of floppy eyelid syndrome with concomitant keratoconus. One patient with bilateral keratoconus had bilateral symmetric floppy eyelid syndrome. The other four patients had asymmetric keratoconus and floppy eyelid syndrome. In all four patients, the keratoconus was significantly worse in the eye with the more severe case of floppy eyelid syndrome. In addition, these four patients all gave a history of sleeping with their head facing predominantly on the side with the floppy eyelid syndrome and keratoconus. Two patients with keratoconus and floppy eyelid syndrome were able to undergo successful contact lens rehabilitation of their keratoconus after treatment of the floppy eyelid syndrome.     

Complications of exposed monofilament sutures

Exposed monofilament suture ends caused a variety of symptoms and signs in 18 patients. These included foreign-body sensation, pain, contact lens intolerance, giant papillary conjunctivitis, tarsal ulceration, conjunctival granuloma, corneal infiltrate, and corneal vascularization. These changes followed cataract surgery, corneal transplantation, and pars plana vitrectomy. Diagnoses in these cases were made by careful slit-lamp examination and by eversion of the upper eyelid. In every case, removal of the sutures or trimming the suture ends resulted in the immediate relief of all symptoms with complete resolution of all signs within two months.     

Surgical management of floppy eyelid syndrome

Four patients (five eyes) with the classic findings of floppy eyelid syndrome all had chronic irritative symptoms, with papillary conjunctivitis, and a soft, rubbery, floppy, and easily everted upper eyelid. All affected eyes were treated surgically by a full-thickness eyelid shortening procedure which produced immediate relief of symptoms. Histopathologic study of the resected eyelids showed only an inflammatory infiltrate in the conjunctiva, but failed to identify specific cause for the lax tarsus.     

Floppy eyelid syndrome and blepharochalasis

Floppy eyelid syndrome and blepharochalasis may represent a spectrum of one underlying disease. Two patients with floppy eyelid syndrome and one with blepharochalasis shared important clinical similarities. All three patients displayed eyelid laxity associated with papillary conjunctivitis and ocular surface abnormalities. Histopathologic findings were similar in the three cases, characterized by chronic conjunctival inflammation with normal tarsal collagen. In all three patients surgical horizontal eyelid shortening led to improvement in symptoms and findings.     

Floppy eyelid syndrome and obstructive sleep apnoea

Floppy eyelid syndrome (FES) is a relatively rare condition of unknown aetiology, commonly described in association with other systemic conditions, particularly with obstructive sleep apnoea--OSA (the most frequent and most significant sleep-related breathing disorder in terms of morbidity and mortality). It is characterized by an extremely enlarged and floppy upper eyelid which can be very easily everted (often spontaneously during sleep). The laterality of the disease corresponds to the side the patient sleeps on. The patient may also present with upper lid ptosis, lash ptosis or trichiasis, lower lid ectropion, chronic papillary conjunctivitis, and chronic corneal disorders. The aim of this study is to report this syndrome, which is often overlooked in eye clinics, and to summarize our experience with its diagnosis and treatment. The correct and early diagnosis of FES may be a clue to the correct diagnosis of, at the time of FES diagnosis, unknown OSA.     

Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: a new surgical approach

PURPOSE: To describe and present the results of a new surgical technique for patients with floppy eyelid syndrome, based on the medial upper eyelid stretching encountered in this condition. METHODS: A case series of 24 patients with floppy eyelid syndrome who where found to have symptomatic predominately medial upper eyelid laxity was analyzed. The history, clinical features, histopathology, and outcome were reviewed after patients underwent medial upper eyelid shortening with or without upper eyelid skin reduction as the first surgical procedure. RESULTS: Of the 24 patients, 18 were men (75%) with a mean age at referral of 56 years, having ocular discomfort and conjunctival irritation/papillary conjunctivitis as the main complaints at presentation. Obesity was present in 96% of cases, with lower eyelid laxity/ectropion (50%) and upper eyelid eyelash ptosis (29%) in conjunction with the upper eyelid laxity. The affected side was related to sleeping habits or recurrent mechanical eyelid trauma. Histologic studies showed a nonspecific inflammatory cell infiltrate and loss of elastin with loose dermal connective tissue. After surgery, complete relief of ocular symptoms and good functional and cosmetic results were present in all cases after 18 months of follow-up. CONCLUSIONS: This new surgical approach is based on the presence of predominately medial upper laxity in patients with floppy eyelid syndrome. The excision of this stretched area stabilized the upper eyelid in an anatomic fashion, providing a good and stable long-term result. The possible mechanisms involved in the medial upper eyelid stretching are discussed.     

Syndrome of the flaccid eyelid (floppy eyelid syndrome

Three patients with increasing swelling of the lateral half of the upper lid associated with chronic papillary conjunctivitis which did not respond to therapy were observed. The history, clinical findings, keratinized epithelial cells in the scrapings and the therapeutic success with a protective shield over night suggested the diagnosis of floppy eyelid syndrome.     

Floppy eyelid syndrome: a case report and clinical review.

Floppy eyelid syndrome is a clinical entity associated with a chronic papillary conjunctivitis which is resistant to topical therapeutic agents. The disorder is usually found in older, obese males with upper eyelids which are loose, rubbery, and easily everted. This paper is a review of the clinical characteristics and treatment of the syndrome and includes a case of a 16-year-old male with floppy eyelid syndrome, one of the youngest reported.     

Floppy eyelid syndrome.

The results of clinical examinations and follow-up of 7 patients with floppy eyelid syndrome are presented. The most prominent features of the syndrome are floppy upper eyelids that can be easily everted, with papillary conjunctivitis and punctate keratopathy. The ocular changes seem to be the result of an underlying metabolic (or endocrine) disorder. In the patient with the longest follow-up period (10 years) considerable loss of body weight resulted in a dramatic relief of ocular symptoms.     

Floppy eyelid syndrome associated with keratoconus.

Keratoconus has been associated with various ocular and systemic disorders. It has been linked, in a few cases, with floppy eyelid syndrome (a disorder characterized by a soft rubbery upper tarsus, papillary conjunctivitis and obesity). A 40-year-old male presented with a complaint of gradually decreasing vision in the right eye. An intermittent right exotropia had become constant and he was unable to maintain fixation voluntarily. Corneal findings were consistent with keratoconus. Floppy eyelid syndrome was also diagnosed. An underlying connective tissue disorder may link these two disorders.     

Bilateral corneal neovascularization and floppy eyelid syndrome. A case report]

The conjunctival and corneal lesions usually observed in the floppy eyelid syndrome are benign and reversible as soon as the specific treatment of superior palpebral hyperlaxity is performed. A case of bilateral corneal vascularization, a rare but severe complication of floppy eyelid syndrome is reported. The floppy eyelid syndrome was identified late because keratoconjunctivitis was clinically predominant and palpebral tonicity was not initially considered. The treatment of palpebral hyperlaxity was the prerequisite for good results with keratoplasty.     

Surgical management of seventh nerve paralysis and floppy eyelid syndrome

A seven-stage approach to the management of the paretic eyelid complex has been described. These stages include supportive care, planning and execution of general facial reanimation, lower eyelid and canthal resuspension or support, passive upper eyelid animation, dynamic lid animation, and soft tissue repositioning. A final stage, the epilogue, is described for the treatment of the synkinesis and hypertonicity that often develop. Recent developments in these areas are discussed. Floppy eyelid syndrome, first described by Culbertson and Ostler, is a syndrome of chronic papillary conjunctivitis in overweight patients with easily everted eyelids. The syndrome has now been associated with a variety of other conditions and findings. Surgical management with horizontal shortening of the floppy eyelids remains the mainstay of therapy.     

软接触镜并发症临床分析

统计分析软接触镜致眼部并发症434例(737眼),其中急性红眼反应162例(37.3%),滤泡性结膜炎或巨乳头状结膜炎54例(12.4%),角膜浸润147例(33.9%),角膜溃疡62例(14.3%),角膜新生血管2例(0.5%)及角膜上皮片状损伤7例(1.6%)。统计结果显示长戴型软接触镜比日戴型具有更大的危险性。     

Giant papillary conjunctivitis following cataract extraction

Out of a series of 600 cataract extractions, 14 patients were found to have giant papillary conjunctivitis (GPC) due to 10-0 nylon sutures. When renewed conjunctival irritation appears weeks or months after surgery, GPC should be suspected and confirmed by eversion of the upper eyelid at the slit lamp. Free edges of protruding corneoscleral nylon sutures should be looked for. Signs and symptoms of GPC disappear within one to four weeks after removal of the offending suture.     

Eyelid, conjunctival, and corneal findings in sleep apnea syndrome.

OBJECTIVE: To determine the prevalence of eyelid, conjunctival, and corneal findings in patients with sleep apnea syndrome (SAS). DESIGN: Case series. PARTICIPANTS: Seventy-two white patients referred for evaluation of suspected SAS. INTERVENTION: Complete examination of eyelids, conjunctiva, and cornea, including videokeratography. MAIN OUTCOME MEASURES: Spearman rank correlations were determined between the respiratory disturbance index (RDI) during night sleep, a value used to diagnose and grade SAS, and tear film break-up time, eyelid distraction distance, presence or absence of ocular irritation symptoms, blepharoptosis, floppy eyelids, lacrimal gland prolapse, keratoconus, and endothelial dystrophy. Each correlation was controlled for age and body mass index. RESULTS: According to the RDI, 44 (61 %) of the 72 patients had SAS. The RDI correlated positively with the eyelid distraction distance (P = 0.05), presence or absence of floppy eyelids (P = 0.01), and lacrimal gland prolapse (P = 0.01), and correlated negatively with tear film break-up time (P = 0.02). None of our patients with floppy eyelids had corneal abnormalities. One patient with SAS had bilateral keratoconus; another had bilateral Fuch endothelial dystrophy. CONCLUSIONS: Sleep apnea syndrome was significantly associated with reduced tear film break-up time, floppy eyelids, and lacrimal gland prolapse. However, ocular irritation symptoms and corneal involvement were rare among patients with SAS. These findings do not confirm previous studies that reported a high prevalence of corneal involvement in floppy eyelid syndrome.     

Floppy eyelid syndrome and mental retardation

OBJECTIVE: To report four subjects with a combination of floppy eyelid syndrome, mental retardation, and increased mechanical stimulus to the affected side. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: The authors retrospectively reviewed the charts of four mentally retarded subjects with floppy eyelid syndrome. INTERVENTION: Surgical tightening of three upper lids and one lower lid was performed in three subjects. MAIN OUTCOME MEASURE: Relief of symptoms. RESULTS: The affected eyelids were treated surgically; in case 1 by anterior lamellar repositioning and lateral and medial canthal tightening, in case 2 by horizontal upper lid shortening, and in case 3 by horizontal lid shortening of both upper and lower lids. There was marked relief from symptoms in all three cases. In case 4, surgery was deferred at parental request. CONCLUSIONS: These cases support the role of mechanical factors in the pathogenesis of floppy eyelid syndrome. Subjects with mental retardation may cooperate poorly with examination, and we believe that there should be a careful search for floppy eyelid syndrome in the presence of chronic conjunctivitis or unexplained epitheliopathy.     

Differential diagnosis and therapy of gigantopapillary conjunctivitis

If wearers of contact lenses present with secretion and incompatibility of the contact lens, simple ectropionation of the upper eyelids often is sufficient to diagnose a giant papillary conjunctivitis as the cause. This form of papillary hypertrophy affecting wearers of both hard and soft contact lenses is morphologically similar to vernal conjunctivitis, which should be considered in cases of corneal ulceration resistant to therapy. The histological difference between the two forms of papillary hypertrophy is that contact lens-induced giant papillary conjunctivitis shows remarkably less eosinophilic infiltration of the papillary stroma. Both forms of papillary hypertrophy seem to be based on a complex immunologic reaction.     

眼红斑痤疮临床表现及治疗分析

目的研究眼红斑痤疮临床表现、并发症情况及相关治疗。方法对眼红斑痤疮患者先用肉眼观察,然后用裂隙灯显微镜检查眼部,用其弥散光线观察面部皮肤细微改变,尤其是血管异常。结果 88例中男性58例(66%),女性30例(44%)。就诊年龄最小3岁,最大84岁,平均55.8岁,40岁以上71例(80.7%)。睑缘结膜炎84例(95.5%),结膜炎4例(睑缘正常)(4.5%)。下方角膜血管翳13例(14.8%)16只眼(双眼3例);结节性结膜炎及表层点状角膜炎(双眼)各2例(各占2.3%)。角膜基质深层血管增生、丝状角膜炎、肉芽肿性结膜炎(双眼)、结膜瘢痕、无菌性角膜溃疡、双上睑皮炎各1例(各占1.1%)。结膜下出血4例(4.5%);霰粒肿3例,内麦粒肿2例。面部包括睑缘附近皮肤均有不同程度血管增生或红斑,其中肥大性酒糟鼻3例(3.4%)。结论眼红斑痤疮侵犯眼表及眼前节某些组织,面部及眼表血管异常是基本依据,结合其他重要所见则明确诊断。