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Floppy Eyelid Syndrome Treatment & Management

  • Author: Mark Ventocilla, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Feb 22, 2016
 

Approach Considerations

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.

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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.

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Surgical Intervention

Upper and lower eyelids can be tightened at the lateral canthus by using a standard lateral tarsal strip procedure.[18]

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.[21]

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.[22] 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
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Consultations

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)
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Long-Term Monitoring

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.

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Contributor Information and Disclosures
Author

Mark Ventocilla, OD, FAAO Adjunct Clinical Professor, Michigan College of Optometry; Editor, American Optometric Association Ocular Surface Society Newsletter; Chief Executive Officer, Elder Eye Care Group, PLC; Chief Executive Officer, Mark Ventocilla, OD, Inc; President, California Eye Wear, Oakwood Optical

Mark Ventocilla, OD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Sean M Blaydon, MD, FACS Fellowship Program Director, Texas Oculoplastic Consultants

Sean M Blaydon, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, International College of Surgeons US Section, Pan-American Association of Ophthalmology, Pan-Pacific Surgical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Jorge G Camara, MD Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine

Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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