Floppy Eyelid Syndrome Treatment & Management

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