Floppy Eyelid Syndrome Clinical Presentation

Updated: Jul 20, 2018
  • Author: Mark Ventocilla, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD  more...
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Presenting symptoms of floppy eyelid syndrome (FES) include the following:

  • Unilateral or bilateral chronic eye irritation and burning

  • Tearing

  • Ropy, mucoid discharge (usually worse in the morning)

  • Decreased vision (if there is an associated keratopathy)

  • Daytime somnolence

  • Morning headaches

The sleep history includes the following:

  • Usual sleep position on one side or prone with the face in the pillow

  • Frequent episodes of waking up during the night

The past ocular history may include the following:

  • Chronic papillary conjunctivitis

  • Chalazia or hordeola

  • Keratoconus

  • Contact lens use

  • Intermittent symptoms, which may be seasonal due to associated allergy

The past medical history may include the following:

  • Acne rosacea

  • Psoriasis

  • Hypertension

  • Congestive heart failure (CHF)

  • Obstructive sleep apnea (OSA)


Physical Examination

External ophthalmic examination typically reveals the following:

  • Lax upper eyelid that is easily everted when pulled superiorly toward the eyebrow (see the first image below)

  • Soft and rubbery tarsal plate that can be folded upon itself

  • Laxity that can be quantified through measurement of anterior eyelid distraction [16]

  • Atrophic tarsal plate

  • Stringy, mucoid conjunctival discharge

  • Punctate corneal epitheliopathy and mucous strands in the tear film and fornices (possibly)

  • Eyelash ptosis (see the second image below) with loss of lash parallelism (ie, lashes point downward toward the cornea and curve in different directions) [8]

    Floppy eyelid syndrome. Lax, rubbery upper eyelid Floppy eyelid syndrome. Lax, rubbery upper eyelid is easily everted as it is pulled up toward eyebrow. Conjunctival hypertrophy and inflammation are present, in addition to mucoid discharge.
    Floppy eyelid syndrome. Eyelash ptosis in patient Floppy eyelid syndrome. Eyelash ptosis in patient with laxity of upper eyelid.

Periorbital involutional changes that may be noted are as follows:

  • Brow ptosis

  • Eyelid dermatochalasis

  • Blepharoptosis

  • Attenuation or dehiscence of the lateral canthal tendon

  • Lacrimal gland prolapse

  • Involutional enophthalmos

  • Lagophthalmos

Slit-lamp examination commonly demonstrates the following:

  • Lash debris

  • Superior papillary tarsal conjunctival hypertrophy

  • Superior bulbar conjunctival injection

  • Punctate fluorescein staining of the superior cornea and conjunctiva

  • Areas of devitalized epithelium and filamentary conjunctivitis with rose bengal or lissamin green stain

  • Superficial corneal pannus at the superior limbus

  • Paracentral thinning of the cornea, consistent with keratoconus