• A 49 y/o male was referred for evaluation of chronic keratitis in his right eye.
• Patient complained of irritation, burning, redness, blurry vision and light sensitivity worse in the morning.
• Ocular history was remarkable for keratitis OD, dry eye OU, allergic conjunctivitis OU and corneal scar OS secondary to traumatic injury in 1974.
• Current ocular medications included Restasis 1 gtt bid OU and GenTeal 1 gtt qid OU.
• The keratitis was refractory to bandage contact lens therapy.
• Systemic history was remarkable for seasonal allergies and smoking.
• Patient stated an allergy to penicillin.

BCVA: OD) 20/30 OS) 20/15-1
PERRL (-) APD
SLE: OU) 2-3+ meibomian gland congestion and injection of lid margin, 1+ conjunctival injection, punctate keratitis OD>>OS, thin tear film and near immediate tear break up time, anterior chambers deep and clear, iris normal, 1+ nuclear sclerosis

Preliminary diagnosis of meibomian gland dysfunction (MGD) with ocular surface disease OD>OS was made. The patient was placed on oral doxycycline 100 mg bid, Restasis 1 gtt bid OU and Systane 1 gtt qid OU and requested to return in 3 weeks.

At the follow-up visit, the patient stated his eyes “are as bad or worse than they have ever been” and that the right eye was very painful. The patient was questioned regarding his sleep habits and stated that he usually slept on his right side. He said his girlfriend thinks he has sleep apnea. Family history was remarkable for 2 brothers diagnosed with sleep apnea.

Both eyelids were easily everted with rubbery tarsus on repeat examination.

Floppy Eyelid Syndrome OD>OS

1. Wear eye shield at bedtime
2. Continue doxycycline 100 mg bid
3. Continue Restasis and Systane and apply lubricating ointment at bedtime

Patient said comfort and vision have improved considerably. SLE indicated near complete resolution of the keratitis. Patient was instructed to continue wearing the eye shield at bedtime, to complete his current prescriptions of doxycycline and Restasis and continue Systane 1 gtt qid OU. If he suffers recurring episodes, the patient was advised that consultation with an oculoplastic specialist may be warranted. Referral to a sleep disorder clinic was also discussed and advised.