Floppy Eyelid Syndrome - Causes, Symptoms, and Treatment

Introduction

Floppy eyelid syndrome is a cause of chronic non-infectious syndrome where eyelids become loose, rubbery, and easily flipped over, which means there is inflammation of the lid and palpebral conjunctiva. There are loose floppy eyelids with punctate epithelial keratopathy, ptosis of lateral eyelashes (when the upper eyelid droops over the eye), and typical conjunctival changes. It can involve both or one upper eyelid or lower eyelid. Floppiness of the eyelid occurs because of the laxity of the tarsus, and the reason behind this is the decrease in tarsal elastin. It is seen in obese males during middle age. Several systemic diseases are associated with floppy eyelid syndrome. Patients suffering from floppy eyelid syndrome usually have a long history of chronic eye irritation with discharge in the morning and pre-existing obstructive sleep apnea. Conservative treatment of floppy eyelid syndrome is lubrication, eye shield during the night time, and appropriate sleeping habits. After long-term therapy with continuous positive airway pressure, patients suffering from floppy eyelid syndrome and obstructive sleep apnea may show improvement in ocular signs and symptoms. In refractory cases, surgery can result in overall improvement. Culbertson and Ostler first described it in 1981.

What Are the Causes of Floppy Eyelid Syndrome?

• Reduced Amount of Elastin: It occurs because of repeated mechanical stress, eye rubbing, or sleeping down with their eyes pressed on the pillow. Decreased elastin leads to chronic irritation in the eyelids. This disorder can be unilateral or bilateral

• Poor Contact of the Lax Eyelid With the Globe: Poor contact of the lax eyelid with the globe may also contribute to this syndrome. Floppy eyelid syndrome may arise when there is an abnormality with the meibomian gland and tear film.

• Obstructive Sleep Apnoea: Obstructive sleep apnoea may also lead to floppy eyelid syndrome and ocular ischemia, which can be exacerbated by hypoventilation caused by obstructive sleep apnea.

• Obesity: Floppy eyelid syndrome is closely associated with obesity in males.

• Down Syndrome: Eyelid eversion is also associated with floppy eyelid syndrome.

• Keratoconus: Keratoconus is defined as mechanical irritation caused due to eye rubbing. It can be a cause of floppy eyelid syndrome.

• Past Medical History: Patients risk developing floppy eyelid syndrome suffering from psoriasis, hypertension, and congestive heart failure.

What Are the Symptoms Associated With Floppy Eyelid Syndrome?

• Irritation in eyes and itching of eyes, especially after waking up.

• Discharge from the eyes.

• Blepharoptosis is a low-lying upper eyelid margin.

• Dermatochalasis (presence of loose redundant eyelid skin).

• Ulceration in the cornea.

• Scarring in the cornea.

• Infectious keratitis (infection of the cornea caused by bacteria).

• Burning sensation in eyes.

• Excessive tearing.

• Reduced eye vision.

• Drowsiness (somnolence).

• Headache in the morning.

• Glaucoma (an eye disorder that can lead to vision loss by damaging the optic nerve).

What Is the Diagnosis of Floppy Eyelid Syndrome?

There is no such diagnosis for this condition. Clinical diagnosis is based on the syndrome's history, clinical features, and systemic association of diseases. Diagnosis mainly depends on the papillary changes in the conjunctiva and the eversion of tarsal plates.

What Is the Differential Diagnosis of Floppy Eyelid Syndrome?

It must be distinguished from conditions like the following:

● Allergic conjunctivitis (inflammatory response of conjunctiva because of allergen).

● Ectropion (a condition where the eyelid turns outward).

● Atopic keratoconjunctivitis (inflammatory eye condition seen in patients with atopic dermatitis).

● Giant papillary conjunctivitis (when the eye gets red, swollen, and inflamed).

● Superior limbic keratoconjunctivitis (rare chronic inflammatory condition of bulbar conjunctiva).

● Dermatochalasis (loose redundant tissues below the eyes).

What Is the Treatment Associated With Floppy Eyelid Syndrome?

Medical Treatment:

Medical treatment consists of the following:

• Avoid rubbing your eyes.

• Mechanical shielding of eyelids with the help of tape may prevent floppy eyelid syndrome.

• Topical lubricant can be used to reduce irritation and discomfort in the eyes.

• Eye shields such as sleep masks can also be used to prevent this syndrome by interrupting the lid pillow contact during sleep.

Surgical Treatment:

Surgical treatment is done when conservative treatment does not improve the patient's condition. Surgical treatment aims at improving the condition and position of the eyelids. The treatment consists of:

• Horizontal Shortening of Eyelids: Horizontal shortening can help treat floppy eyelid syndrome.

• Lateral Canthopexy: Lateral canthopexy is more effective than floppy eyelid syndrome.

• Tarsorrhaphy: For patients who do not respond to the above techniques, Tarsorrhaphy is done in these cases to prevent eyelid eversion.

Complications of surgical treatment include delayed wound healing, unacceptable eyelid height, and under-correction or overcorrection can be there.

What Are the Complications of Floppy Eyelid Syndrome?

Floppy eyelid syndrome is a condition where the upper eyelid becomes loose and easily everted, leading to a number of potential complications. Some of the possible complications of FES include:

• Chronic Irritation: The chronic rubbing of the eye against a floppy eyelid can cause eye irritation, inflammation, and redness.

• Corneal Abrasions: The constant friction between the eyelid and the eye's surface can cause scratches or abrasions on the cornea, which can be painful and lead to blurred vision.

• Conjunctivitis: The chronic irritation caused by floppy eyelid syndrome can also lead to an infection of the conjunctiva, the thin membrane that lines the inner surface of the eyelid and the white part of the eye.

• Obstructive Sleep Apnea: Floppy eyelid syndrome has been linked to obstructive sleep apnea, a serious condition that causes breathing to repeatedly stop and start during sleep.

• Dry Eye Syndrome: Floppy eyelids can cause tears to evaporate more quickly from the surface of the eye, leading to dry eye syndrome, which can cause discomfort, burning, and blurry vision.

• Vision Loss: In rare cases, floppy eyelid syndrome can lead to vision loss due to corneal scarring or other complications.

Conclusion

Floppy eyelid syndrome is a rare disorder that is often underdiagnosed. It is associated with ocular and systemic diseases such as keratoconus, hypertension, diabetes, congestive heart failure, and obstructive sleep apnea. Its conservative treatment includes thick lubricating gel at night and the use of an eyeshield. Sleeping with a cylindrical pillow will also help minimize eye contact and pillow contact at night. Using a sleep mask and taping of eyelids will prevent the eversion of eyelids. Patients suffering from obstructive sleep apnea may show improvement in the eyes after long-term positive air pressure therapy. Corrective surgery is generally recommended for refractory cases, resolving lid laxity problems. All patients with severe ocular irritation should be screened for floppy eyelid syndrome.