Floppy Eyelid Syndrome

Chronically red, irritated eye(s) with mild mucous discharge, often worse upon awakening due to eyelid eversion during sleep. Usually bilateral, but often asymmetric. Typically seen in obese patients due to the strong association with sleep apnea, with a slight male predilection.

Signs ⬆ ⬇

Critical

Upper eyelids are easily everted without an accessory finger or cotton-tipped applicator exerting counterpressure.

Other

Rubbery, atrophic superior tarsal plate with conjunctival injection and chronic papillary conjunctivitis, SPK, ptosis with lash ptosis, and/or lower eyelid laxity. Associations include obstructive sleep apnea, obesity, keratoconus, and Down syndrome.

Differential Diagnosis ⬆ ⬇

The key differentiating factor is increased horizontal laxity and spontaneous eversion of the upper eyelids.

Vernal conjunctivitis: Seasonal, itching, and giant papillary reaction. See 5.2, CHRONIC CONJUNCTIVITIS.
Giant papillary conjunctivitis: Often related to contact lens wear or an exposed suture. See 4.21, CONTACT LENS–INDUCED GIANT PAPILLARY CONJUNCTIVITIS.
Superior limbic keratoconjunctivitis: Hyperemia, thickening, and inflammation of the superior bulbar conjunctiva, limbus, and cornea. Often associated with thyroid dysfunction, keratoconjunctivitis sicca, and rheumatoid arthritis. See 5.4, SUPERIOR LIMBIC KERATOCONJUNCTIVITIS.
Toxic keratoconjunctivitis: Papillae or follicles are typically more pronounced inferiorly in patients using eye drops. See 5.2, CHRONIC CONJUNCTIVITIS.
Ectropion: Outward turning of the eyelid margin, often leading to tearing, irritation, and eyelid thickening. See 6.3, ECTROPION.

Etiology ⬆ ⬇

The underlying etiology is not definitively known. Studies have suggested locally elevated matrix metalloproteinase (MMP) levels and elastin loss. Symptoms are thought to result from spontaneous eversion of the upper eyelid during sleep, allowing the superior palpebral conjunctiva to rub against pillows or sheets. Unilateral or asymmetric symptoms occur in those who tend to sleep prone on the affected side.

Work Up ⬆ ⬇

Workup

Pull the upper eyelid toward the patient’s forehead to determine if it spontaneously everts or is abnormally lax.
Conduct slit lamp examination of the cornea and conjunctiva with fluorescein staining, looking for superior palpebral conjunctival papillae and SPK.
Ask about history of snoring and obstructive sleep apnea.

Treatment ⬆ ⬇

Topical antibiotic ointment for any mild corneal or conjunctival abnormality (e.g., erythromycin ointment b.i.d. to q.i.d.). May change to artificial tear ointment when lesions resolve.
The eyelids may be taped closed during sleep, or a shield may be worn to protect the eyelid from rubbing against the pillow or bed. Patients are asked to refrain from sleeping face down. Asking patients to sleep on their contralateral side may be therapeutic as well as diagnostic.
Surgical horizontal tightening of the eyelid with lateral tarsal strip or wedge resection is often required for definitive treatment.

Follow Up ⬆

Every few days to weeks initially, followed by weeks to months as the condition stabilizes.
Refer to an internist, otolaryngologist, or pulmonologist for evaluation and management of possible obstructive sleep apnea. Evaluation is important because of the systemic sequelae of untreated sleep apnea and for anesthesia risk assessment before eyelid surgery.