Floppy Eyelid Syndrome 

Floppy eyelid syndrome (FES) was initially described by Culbertson and Ostler in 1981.^[1] Floppy eyelid syndrome was seen in overweight male patients with floppy, rubbery, and easily everted upper eyelids associated with chronic papillary conjunctivitis of the upper palpebral conjunctiva. See the image below.

Floppy eyelid syndrome often is unrecognized. Unsuccessful trials of artificial tears, vasoconstrictors, or topical steroids and antibiotics have already occurred before the correct diagnosis is made.

Although floppy eyelid syndrome has been reported in nonobese patients, it is seen more frequently in patients who are obese. The condition often is associated with obstructive sleep apnea (OSA).^{[2, 3, 4, 5]}

Patients with obstructive sleep apnea experience episodic apnea and hypopnea due to obstruction of the upper airway. When these patients sleep on their backs, a collapse of the pharynx occurs during inspiration, resulting in loud snoring and eventual apnea, which causes the patient to awaken. Obstructive sleep apnea eventually can lead to systemic or pulmonary hypertension, congestive heart failure, and cardiac arrhythmia.

Obstructive sleep apnea is associated with other serious ocular disorders, such as glaucoma, ischemic optic neuropathy, and papilledema secondary to increased intracranial pressure. Treatment of obstructive sleep apnea can reduce intracranial pressure and secondary papilledema.

Patients with floppy eyelid syndrome usually present with a long history of unilateral or bilateral ocular irritation, and discharge with either a preexisting diagnosis of obstructive sleep apnea or a history of snoring.

Although tarsal collagen appears normal in patients with floppy eyelid syndrome, several histopathologic studies have demonstrated a significant decrease in tarsal elastin using special stains, immunohistochemistry, and electron microscopy.^{[6, 7, 8]}

• The rubbery consistency and laxity of the tarsus may be related to the decrease in elastin.
• Eyelid laxity allows upper eyelid eversion on contact with a pillow during sleep, resulting in mechanical irritation and inflammation of the conjunctiva.
• Patients who sleep on one side more than the other side tend to have more severe changes on that side. This finding suggests mechanical injury as the primary cause of the papillary conjunctivitis.
• In many cases of floppy eyelid syndrome, there is a history of loud snoring or a diagnosis of obstructive sleep apnea, requiring the patient to sleep on their side or in a prone position with their face in the pillow.
• Use of an eye shield to protect the eyelids during sleep often can improve the patient's signs and symptoms.

Floppy eyelid syndrome has been associated with keratoconus, which also suggests mechanical irritation from eye rubbing as a contributing factor.^[9]

Others have postulated that the cause of the chronic conjunctivitis is poor apposition of the lax upper eyelid to the globe with inadequate spreading of the tear film.^[10] This condition leads to corneal and conjunctival compromise, rather than direct mechanical irritation.

Meibomian gland dysfunction and atrophy can be found in association with floppy eyelid syndrome.^[11]

• Light microscopy of surgical specimens has revealed Demodex brevis infestation.^[12]
• The Demodex mite destroys the meibomian glands, resulting in tear film abnormalities, increased tear evaporation, and a gradual atrophy of the tarsus.

Frequency

United States

Floppy eyelid syndrome is uncommon but underrecognized.

Mortality/Morbidity

• Obstructive sleep apnea is a potentially fatal disorder. Frequent episodes of apnea and hypopnea can lead to systemic and pulmonary hypertension and, ultimately, congestive cardiomyopathy. Patients with obstructive sleep apnea may complain of morning headaches and daytime somnolence, resulting in poor work performance and an increased risk of automobile accidents.^[13]
• Corneal erosions secondary to nocturnal eyelid eversion can result in corneal ulceration and scarring that can lead to permanent decreased vision.
• Chronic conjunctivitis, punctate keratopathy, and corneal neovascularization can result in contact lens intolerance.

Race

Although most reported cases have involved white patients, there is probably no racial predilection.

Sex

Incidence of floppy eyelid syndrome is slightly more prevalent in men than in women.^{[9, 10]}

Age

Floppy eyelid syndrome most commonly is diagnosed among middle-aged patients (40-50 years). Previous reports have noted floppy eyelid syndrome among patients aged 25-80 years.^[10]