Floppy Eyelid Syndrome Treatment & Management
- Author: Mark Ventocilla, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD more...
More conservative medical care often proves inadequate in relieving symptoms of floppy eyelid syndrome (FES). In many cases, surgical intervention is required, usually involving the tightening of the lax upper eyelid, which can be achieved in a number of ways.
Floppy eyelid syndrome is usually treated on an outpatient basis. Patients who are obese should be encouraged to lose weight.
Conservative Medical Therapy
Topical application of a lubricating or antibiotic ophthalmic ointment in the affected eye is indicated for mild corneal or conjunctival abnormalities. Erythromycin ophthalmic may be applied 2-4 times daily for superior punctate keratitis. (See Medication.) Lubricating ophthalmic ointment may be applied at bedtime.
If meibomian gland dysfunction is suspected, trial of an oral tetracycline (eg, such as doxycycline 100 mg once or twice daily for 6-12 wk) may be appropriate.
In addition, the patient should be instructed to tape the eyelids closed and wear an eye shield while asleep to protect the conjunctiva and the eye from rubbing on the pillow.
Upper and lower eyelids can be tightened at the lateral canthus by using a standard lateral tarsal strip procedure.
Horizontal shortening of the lateral upper eyelid can be achieved by performing a full-thickness resection of the lateral one fourth to one third of the eyelid margin.[19, 20] This can be accomplished by means of a vertical full-thickness resection up to an eyelid crease incision. Ptosis repair or blepharoplasty can be performed at the same time. The disparity in skin length can be managed with a vertical Burow triangle directed toward the brow at the lateral extent of the eyelid crease incision.
A modified curvilinear back-tapered full-thickness resection with an advancement flap at the lateral upper eyelid has also been described.
In cases with more medial laxity, horizontal shortening of the medial upper eyelid can be achieved by performing a laterally displaced pentagonal full-thickness resection in the medial one third of the eyelid, lateral to the superior punctum. Any brow ptosis, dermatochalasis, blepharoptosis, or ectropion can be repaired at the same time.
In repairing ptosis of a lax upper eyelid, the eyelid often must be tightened to achieve the desired contour.
Complications of surgical treatment of FES include the following:
Poor wound healing
Unacceptable eyelid height or contour
Undercorrection or overcorrection
The following consultations may be useful:
Oculoplastic (if upper eyelid tightening and ptosis repair are required and the referring physician is uncomfortable with the procedure)
Internal medicine, pulmonary medicine, or otolaryngology (for evaluation and medical management of possible obstructive sleep apnea [OSA])
Head and neck surgery (if patient medical management of OSA has failed)
Patients treated for FES should be observed every 3-7 days initially until any keratitis is resolved; after the first week, they may be observed every 2-6 weeks, as necessary.
Antibiotic ophthalmic ointment (eg, erythromycin) is prescribed postoperatively 2-4 times a day along sutures and in the eye for 1 week. (See Medication.) Lubricating ophthalmic ointment in the eye at bedtime can be continued, as needed.
Patients with should be encouraged to refrain from sleeping with the face in the pillow, to avoid rubbing the eyes, and to lose weight if obese. Special shields or a mask may have to be fitted to shield the eye from mechanical irritation.
Culbertson WW, Ostler HB. The floppy eyelid syndrome. Am J Ophthalmol. 1981 Oct. 92(4):568-75. [Medline].
McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg. 1997 Jun. 13(2):98-114. [Medline].
McNab AA. The eye and sleep. Clin Experiment Ophthalmol. 2005 Apr. 33(2):117-25. [Medline].
Karger RA, White WA, Park W, et al. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Ophthalmology. Sep 2006. 113(9):1669-74. [Medline].
Chambe J, Laib S, Hubbard J, Erhardt C, Ruppert E, Schroder C, et al. Floppy eyelid syndrome is associated with obstructive sleep apnoea: a prospective study on 127 patients. J Sleep Res. 2011 Oct 11. [Medline].
Muniesa MJ, Huerva V, Sánchez-de-la-Torre M, Martínez M, Jurjo C, Barbé F. The relationship between floppy eyelid syndrome and obstructive sleep apnoea. Br J Ophthalmol. 2013 Apr 12. [Medline].
Pihlblad MS, Schaefer DP. Eyelid laxity, obesity, and obstructive sleep apnea in keratoconus. Cornea. 2013 Sep. 32(9):1232-6. [Medline].
Netland PA, Sugrue SP, Albert DM, et al. Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology. 1994 Jan. 101(1):174-81. [Medline].
Schlotzer-Schrehardt U, Stojkovic M, Hofmann-Rummelt C, et al. The pathogenesis of floppy eyelid syndrome: involvement of matrix metalloproteinases in elastic fiber degradation. Ophthalmology. 2005 Apr. 112(4):694-704. [Medline].
Ezra DG, Ellis JS, Gaughan C, Beaconsfield M, Collin R, Bunce C, et al. Changes in tarsal plate fibrillar collagens and elastic fibre phenotype in floppy eyelid syndrome. Clin Experiment Ophthalmol. 2011 Aug. 39(6):564-71. [Medline].
van Nouhuys HM, van den Bosch WA, Lemij HG, Mooy CM. Floppy eyelid syndrome associated with Demodex brevis. Orbit. Sep 1994. 13(3):125-9.
Donnenfeld ED, Perry HD, Gibralter RP, et al. Keratoconus associated with floppy eyelid syndrome. Ophthalmology. 1991 Nov. 98(11):1674-8. [Medline].
Goldberg R, Seiff S, McFarland J, et al. Floppy eyelid syndrome and blepharochalasis. Am J Ophthalmol. 1986 Sep 15. 102(3):376-81. [Medline].
Gonnering RS, Sonneland PR. Meibomian gland dysfunction in floppy eyelid syndrome. Ophthal Plast Reconstr Surg. 1987. 3(2):99-103. [Medline].
Findley LJ, Unverzagt ME, Suratt PM. Automobile accidents involving patients with obstructive sleep apnea. Am Rev Respir Dis. 1988 Aug. 138(2):337-40. [Medline].
Iyengar SS, Khan JA. Quantifying upper eyelid laxity in symptomatic floppy eyelid syndrome by measurement of anterior eyelid distraction. Ophthal Plast Reconstr Surg. 2007 May-Jun. 23(3):255. [Medline].
Schwartz LK, Gelender H, Forster RK. Chronic conjunctivitis associated with 'floppy eyelids'. Arch Ophthalmol. 1983 Dec. 101(12):1884-8. [Medline].
Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. 1989 Apr. 107(4):604-6. [Medline].
Dutton JJ. Surgical management of floppy eyelid syndrome. Am J Ophthalmol. 1985 May 15. 99(5):557-60. [Medline].
Moore MB, Harrington J, McCulley JP. Floppy eyelid syndrome. Management including surgery. Ophthalmology. 1986 Feb. 93(2):184-8. [Medline].
Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthal Plast Reconstr Surg. 202 Sep. (18)5:370-2. [Medline].
Valenzuela AA, Sullivan TJ. Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: a new surgical approach. Ophthal Plast Reconstr Surg. 2005 Jul. 21(4):259-63. [Medline].