By Robert Gibbs, OD
PCLI—Yakima, WA

Floppy Eyelid Syndrome (FES) was first termed in 1981 to describe a condition characterized by:

• upper eyelid laxity
• papillary conjunctivitis of the palpebral conjunctiva
• chronic eye irritation

It is usually seen in overweight, middle-aged males with a good percentage of these patients also suffering from obstructive sleep apnea (OSA). However, recent findings suggest a broader patient profile including, women, children, average or underweight patients and patients with hypertension, diabetes, heart disease, cerebrovascular disease and mental retardation.

Exactly what causes FES is not well understood but studies point to an underlying genetic collagen or elastin abnormality that sets off a chain of events:

1. Decreased elastin causes degeneration of collagenous connective tissue in the tarsus—that results in lid laxity.
2. As a result of lid laxity and tendency of these patients to sleep on one side or in a face down position, theory suggests that spontaneous lid eversion occurs—resulting in mechanical abrasion of the ocular surface.

The symptoms of FES are often variable and can mimic many ocular disease processes. Also, keep in mind that if the patient is new to you, there may be a history of chronic irritation that has been resistant to previous medical treatment—including trials of artificial tears, topical antibiotics and steroids, and even bandage contact lens therapy.

Common complaints include:

• unilateral or bilateral chronic dry eye
• irritation
• redness
• tearing
• itching
• blurred vision
• frequent ropy discharge that is worse in the morning

Patients (or their significant others) may also report loud snoring, morning headaches and daytime somnolence or drowsiness.

Thorough lid examination often reveals:

• lids that are easily everted
• brow and/or lid ptosis
• lash ptosis
• trichiasis
• ectropian and meibomian gland dysfunction

Slit lamp examination often shows:

• palpebral papillary conjunctivitis
• superior bulbar conjunctival injection
• punctate epithelial erosions
• filamentary keratitis

Medical treatment for FES consists primarily of lubricating the ocular surface with gels or antibiotic ointment. Topical artificial tears, antibiotics, steroids and non-steroidal anti-inflammatory drugs may be used but are often ineffective. Punctal plugs may provide some relief for severe dry eyes. Any associated blepharitis or meibomian gland dysfunction may warrant a trial of oral doxycycline 100 mg bid for 6-12 weeks.

A trial of covering the affected eye at night with tape, a patch or protective eye shield, should be performed to reduce risk of mechanical irritation during sleep.

Wedge Resection Surgery

Difficult cases that do not respond to primary therapy may require surgery. Horizontal tightening of the upper lid with lateral tarsal strip surgery or wedge resection of the medial and lateral third of the upper eyelid (as shown in the above diagram) have proven to be effective. Marked brow/lid ptosis, dermatochalasis or ectropian can be repaired at the same time.

As optometric physicians, we need to recognize the signs and symptoms of FES and help patients find solutions. By initiating effective treatment, we can reduce the risk of permanent decreased vision due to corneal ulceration and scarring.

As primary care providers, it is also important that we understand the association of obstructive sleep apnea (OSA) with FES—and other eye conditions. OSA has been linked to cases of:

• open angle glaucoma
• normal tension glaucoma
• anterior ischemic optic neuropathy
• pseudotumor cerebri

I encourage you to discuss sleep apnea with FES patients—and any other patients who are troubled by OSA. Ocular association aside, sleep apnea is a potentially fatal disorder. Left untreated it may lead to high blood pressure and cardiovascular disease. More importantly, the loss of adequate sleep may lead to accidental injury or death while on the job or from motor vehicle accidents.

Consultation with the patient's primary care physician and/or a sleep disorder clinic should be part of your management plan for patients with FES. Click here for additional information on sleep apnea.

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