Floppy Eyelid Syndrome

Updated: Jul 20, 2018
Author: Mark Ventocilla, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD 



Floppy eyelid syndrome (FES) was initially described by Culbertson and Ostler in 1981.[1] It had not been recognized as a specific entity prior to this. The syndrome was seen in overweight male patients with floppy, rubbery, and easily everted upper eyelids associated with a variable chronic papillary conjunctivitis of the upper palpebral conjunctiva.

FES, because its symptoms are common to other disease processes, often is not diagnosed at the onset of symptoms. Several unsuccessful trials of artificial tears, vasoconstrictors, topical steroids, nonsteroidal anti-inflammatory drops, or antibiotics may already have taken place before the correct diagnosis is made. Although FES has been reported in nonobese patients, it is seen more frequently in patients who are obese. The condition often is associated with obstructive sleep apnea (OSA).[2, 3, 4, 5, 6, 7]

Patients with OSA experience episodic apnea and hypopnea as a consequence of intermittent obstruction of the upper airway. When these patients sleep on their backs, a collapse of the pharynx occurs during inspiration, resulting in loud snoring and eventual apnea, which causes the patient to awaken. OSA eventually can lead to systemic or pulmonary hypertension, congestive heart failure, and cardiac arrhythmia. OSA is associated with other serious ocular disorders, such as glaucoma, ischemic optic neuropathy, and papilledema secondary to increased intracranial pressure. Treatment of OSA can reduce intracranial pressure and secondary papilledema.

Patients with FES usually present with a long history of unilateral or bilateral ocular irritation and discharge with either a preexisting diagnosis of OSA or a history of snoring.


Although tarsal collagen appears normal in patients with FES, several histopathologic studies using special stains, immunohistochemistry, and electron microscopy have demonstrated a significant decrease in tarsal elastin.[8, 9, 10] The rubbery consistency and laxity of the tarsus may be related to the decrease in elastin. Eyelid laxity allows upper eyelid eversion on inadvertently rubbing the eye or lateral stretching of the lid through contact with a pillow during sleep, resulting in mechanical irritation and inflammation of the conjunctiva.

Light microscopy of surgical specimens has sometimes revealed Demodex brevis infestation.[11] The Demodex mite destroys the meibomian glands, resulting in tear film abnormalities, increased tear evaporation, and gradual atrophy of the tarsus.


Patients who sleep on one side more than the other side tend to have more severe changes on that side. This finding suggests mechanical injury as the primary cause of the papillary conjunctivitis. In many cases of FES, there is a history of loud snoring or a diagnosis of OSA, which requires the patient to sleep on one side or in a prone position with the face in the pillow. Use of an eye shield to protect the eyelids during sleep often can improve the patient’s signs and symptoms.

FES has been associated with keratoconus, which also suggests mechanical irritation from eye rubbing as a contributing factor.[12] Others have postulated that the cause of the chronic conjunctivitis is poor apposition of the lax upper eyelid to the globe with inadequate spreading of the tear film.[13] This condition leads to corneal and conjunctival compromise, rather than direct mechanical irritation. Meibomian gland dysfunction and atrophy can be found in association with FES.[14]


FES is uncommon but underrecognized. It is most commonly diagnosed among middle-aged patients (40-50 years), though it has been reported in patients aged 25-80 years.[13] The incidence of FES is slightly higher in men than in women.[12, 13] Although most reported cases have involved white patients, there is probably no racial predilection.


A medical and surgical approach to managing FES is most often successful in alleviating the patient’s symptoms.

OSA is a potentially fatal disorder. Frequent episodes of apnea and hypopnea can lead to systemic and pulmonary hypertension and, ultimately, congestive cardiomyopathy together with cardiac arrhythmia risk. Patients with OSA may complain of morning headaches and daytime somnolence, which may result in poor work performance and an increased risk of automobile accidents.[15]

Corneal erosions secondary to nocturnal eyelid eversion can result in corneal ulceration and scarring that can lead to permanent decreased vision. Chronic conjunctivitis, punctate keratopathy, and corneal neovascularization may result in contact lens intolerance.

Patient Education

The following items should be discussed with the patient:

  • Significance of sleeping with the face against the pillow

  • Connection between rubbing eyes, keratoconus, and FES

  • Possibility of associated OSA and, if warranted, the need for further tests to evaluate for this condition

  • Treatment options




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





Approach Considerations

In patients with floppy eyelid syndrome (FES), conjunctival scrapings may show the following[17] :

  • Predominance of polymorphonuclear leukocytes (PMNs) with variable amounts of eosinophils and lymphocytes

  • Papillary conjunctival hypertrophy

If obstructive sleep apnea is suspected, the patient should be referred for polysomnography (sleep study).

The tear break-up test (TBUT) result may be less than 10 seconds in FES, indicating tear instability (normal TBUT result, 15-20 seconds).

Light microscopy of surgical specimens may reveal the following:

  • Usual findings of chronic conjunctival inflammation

  • Abnormalities of the meibomian glands, such as granuloma formation

  • Decrease in tarsal elastin



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.

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.

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


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)

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.



Medication Summary

The goals of pharmacotherapy for floppy eyelid syndrome (FES) are to reduce morbidity and to prevent complications.


Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Erythromycin base (E-Mycin)

Erythromycin is indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Azithromycin ophthalmic (AzaSite)

This ophthalmic macrolide antibiotic is indicated for bacterial conjunctivitis caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Doxycycline (Doryx, Vibramycin, Adoxa)

Doxycycline inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Minocycline (Minocin, Solodyn)

Minocycline is a member of the tetracycline class of antimicrobial agents. It is a broad-spectrum agent that inhibits susceptible organisms by blocking their protein synthesis.

Ophthalmic Lubricants

Class Summary

Lubricants act as humectants in the eye. The ideal artificial lubricant should be preservative-free; contain potassium, bicarbonate, and other electrolytes; and have a polymeric system to increase its retention time. Lubricating drops are used to reduce morbidity and to prevent complications. Lubricating ointments prevent complications from dry eyes. Ocular inserts reduce symptoms resulting from moderate-to-severe dry eye syndromes.

Artificial tears (Advanced Eye Relief, Bion Tears, Hypo Tears, Murine Tears, Tears Naturale II)

Artificial tears are used to increase lubrication of the eye. Nonpreserved artificial tears are recommended for use. Tears should be applied liberally throughout the day, and, if necessary, a lubricating ointment may be used at night. This ointment may contain an antibiotic preparation.