History

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

Differential Diagnoses

Culbertson WW, Ostler HB. The floppy eyelid syndrome. Am J Ophthalmol. 1981 Oct. 92(4):568-75. [QxMD MEDLINE Link].
McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg. 1997 Jun. 13(2):98-114. [QxMD MEDLINE Link].
McNab AA. The eye and sleep. Clin Experiment Ophthalmol. 2005 Apr. 33(2):117-25. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pihlblad MS, Schaefer DP. Eyelid laxity, obesity, and obstructive sleep apnea in keratoconus. Cornea. 2013 Sep. 32(9):1232-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Goldberg R, Seiff S, McFarland J, et al. Floppy eyelid syndrome and blepharochalasis. Am J Ophthalmol. 1986 Sep 15. 102(3):376-81. [QxMD MEDLINE Link].
Gonnering RS, Sonneland PR. Meibomian gland dysfunction in floppy eyelid syndrome. Ophthal Plast Reconstr Surg. 1987. 3(2):99-103. [QxMD MEDLINE Link].
Findley LJ, Unverzagt ME, Suratt PM. Automobile accidents involving patients with obstructive sleep apnea. Am Rev Respir Dis. 1988 Aug. 138(2):337-40. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Schwartz LK, Gelender H, Forster RK. Chronic conjunctivitis associated with 'floppy eyelids'. Arch Ophthalmol. 1983 Dec. 101(12):1884-8. [QxMD MEDLINE Link].
Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. 1989 Apr. 107(4):604-6. [QxMD MEDLINE Link].
Dutton JJ. Surgical management of floppy eyelid syndrome. Am J Ophthalmol. 1985 May 15. 99(5):557-60. [QxMD MEDLINE Link].
Moore MB, Harrington J, McCulley JP. Floppy eyelid syndrome. Management including surgery. Ophthalmology. 1986 Feb. 93(2):184-8. [QxMD MEDLINE Link].
Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthal Plast Reconstr Surg. 202 Sep. (18)5:370-2. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

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 with laxity of upper eyelid.

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Author

Mark Ventocilla, OD, FAAO 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

Floppy Eyelid Syndrome Clinical Presentation

History

Physical Examination

References

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