Floppy Eyelid Syndrome Treatment & Management

  • Author: Sean M Blaydon, MD, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Nov 16, 2011
 

Medical Care

  • Topical lubricating or antibiotic ophthalmic ointment in the affected eye is indicated for mild corneal or conjunctival abnormalities.
    • Erythromycin ophthalmic ointment in the eye 2-4 times a day for superior punctate keratitis (See Medication.)
    • Lubricating ophthalmic ointment in the eye at bedtime
  • Trial of a tetracycline, such as doxycycline 100 mg PO qd/bid, may be prescribed if meibomian gland dysfunction is suspected.
  • Have the patient 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 Care

  • More conservative medical care often proves inadequate in relieving symptoms. In most cases, surgical intervention is required, usually involving the tightening of the lax upper eyelid, which can be achieved in a number of ways.
    • Upper and lower eyelids can be tightened at the lateral canthus using a standard lateral tarsal strip procedure.[16]
    • Horizontal shortening of the lateral upper eyelid can be performed by a full-thickness resection of the lateral one fourth to one third of the eyelid margin.[17, 18]
      • This can be accomplished by vertical full-thickness resection up to an eyelid crease incision. Ptosis repair and/or blepharoplasty can be performed at the same time. The disparity in skin length can be managed by a vertical Burrows triangle toward the brow at the lateral extent of the eyelid crease incision.
      • A modified curvilinear back-tapered full-thickness resection with advancement flap at the lateral upper eyelid has also been described.[19]
    • In cases with more medial laxity, horizontal shortening of the medial upper eyelid can be performed by a laterally displaced pentagonal full-thickness resection in the medial one third of the eyelid, lateral to the superior punctum.[20]
  • Any brow ptosis, dermatochalasis, blepharoptosis, or ectropion can be repaired at the same time.
  • When repairing ptosis of a lax upper eyelid, the eyelid often needs to be tightened to achieve the desired contour.
  • Treatment of obstructive sleep apnea
    • Nasal continuous positive airway pressure (CPAP)
    • Surgical intervention usually involves modification of the pharyngeal airway by extirpation of soft tissue (uvulopalatopharyngoplasty) with possible modification of the underlying craniofacial skeleton.
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Consultations

  • Oculoplastic consultation, if upper eyelid tightening and ptosis repair is required and referring physician is uncomfortable with this procedure
  • Referral to internal medicine or pulmonary medicine for evaluation and medical management of possible obstructive sleep apnea
  • Head and neck surgery consultation, if patient has failed medical management of obstructive sleep apnea
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Diet

  • If obese, the patient should be encouraged to lose weight.
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Contributor Information and Disclosures
Author

Sean M Blaydon, MD, FACS  Texas Oculoplastic Consultants, Austin, Texas

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.

Specialty Editor Board

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

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

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, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Culbertson WW, Ostler HB. The floppy eyelid syndrome. Am J Ophthalmol. Oct 1981;92(4):568-75. [Medline].

  2. McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg. Jun 1997;13(2):98-114. [Medline].

  3. McNab AA. The eye and sleep. Clin Experiment Ophthalmol. Apr 2005;33(2):117-25. [Medline].

  4. 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].

  5. 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. Oct 11 2011;[Medline].

  6. Netland PA, Sugrue SP, Albert DM, et al. Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology. Jan 1994;101(1):174-81. [Medline].

  7. 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. Apr 2005;112(4):694-704. [Medline].

  8. 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. Aug 2011;39(6):564-71. [Medline].

  9. Donnenfeld ED, Perry HD, Gibralter RP, et al. Keratoconus associated with floppy eyelid syndrome. Ophthalmology. Nov 1991;98(11):1674-8. [Medline].

  10. Goldberg R, Seiff S, McFarland J, et al. Floppy eyelid syndrome and blepharochalasis. Am J Ophthalmol. Sep 15 1986;102(3):376-81. [Medline].

  11. Gonnering RS, Sonneland PR. Meibomian gland dysfunction in floppy eyelid syndrome. Ophthal Plast Reconstr Surg. 1987;3(2):99-103. [Medline].

  12. 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.

  13. Findley LJ, Unverzagt ME, Suratt PM. Automobile accidents involving patients with obstructive sleep apnea. Am Rev Respir Dis. Aug 1988;138(2):337-40. [Medline].

  14. Iyengar SS, Khan JA. Quantifying upper eyelid laxity in symptomatic floppy eyelid syndrome by measurement of anterior eyelid distraction. Ophthal Plast Reconstr Surg. May-Jun 2007;23(3):255. [Medline].

  15. Schwartz LK, Gelender H, Forster RK. Chronic conjunctivitis associated with 'floppy eyelids'. Arch Ophthalmol. Dec 1983;101(12):1884-8. [Medline].

  16. Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. Apr 1989;107(4):604-6. [Medline].

  17. Dutton JJ. Surgical management of floppy eyelid syndrome. Am J Ophthalmol. May 15 1985;99(5):557-60. [Medline].

  18. Moore MB, Harrington J, McCulley JP. Floppy eyelid syndrome. Management including surgery. Ophthalmology. Feb 1986;93(2):184-8. [Medline].

  19. Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthal Plast Reconstr Surg. Sep 202;(18)5:370-2. [Medline].

  20. 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. Jul 2005;21(4):259-63. [Medline].

 
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A patient with floppy eyelid syndrome. The lax and rubbery upper eyelid is everted easily as it is pulled up toward the eyebrow. Hypertrophy and inflammation of the conjunctiva is present, in addition to a mucoid discharge.
Eyelash ptosis in a patient with laxity of the upper eyelid.
 
 
 
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