Floppy Eyelid Syndrome

Floppy eyelid syndrome (FES) is seen in adult patients with floppy, rubbery, and easily everted upper eyelids associated with chronic papillary conjunctivitis of the upper inner eyelid.  It is often unrecognized. Unsuccessful trials of artificial tears, vasoconstrictors “get-the-red-out eye drops), or topical prescription steroids and/or antibiotics have already occurred before the correct diagnosis is made.

 

Floppy eyelid syndrome can occur in any adult, but it is seen more frequently in patients who are overweight. The condition often is associated with obstructive sleep apnea (OSA).  Patients with floppy eyelid syndrome usually present with a long history of ocular irritation in one eye or both eyes and discharge, often with either a pre-existing diagnosis of obstructive sleep apnea or a history of snoring.

Cause

Possible causes are:

  • The rubbery consistency and laxity of the upper eyelid may be related to the decrease in elastin.

  • Eyelid laxity allows upper eyelid eversion on contact with a pillow during sleep, resulting in mechanical irritation and inflammation of the inner upper eyelid.

  • 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 floppy eyelid syndrome.

  • In many cases of floppy eyelid syndrome there is a history of loud snoring or a diagnosis of obstructive sleep apnea, requiring the patient to sleep on their side or in a prone position with their face in the pillow.

 

Race, Sex and Age

There is probably no racial predilection.  Incidence of floppy eyelid syndrome is slightly more prevalent in men than in women.  Floppy eyelid syndrome is most commonly is diagnosed among middle-aged patients (40-50 years) but can occur from ages 25 to 80.

 

History

  • Presenting symptoms may include:

    • Unilateral or bilateral chronic eye irritation, tearing and/or burning.

    • Stringy, mucoid discharge; usually worse in the morning.

    • Decreased vision, if there is an associated corneal irritation.

    • Daytime drowsiness.

    • Morning headaches.

  • Sleep history

    • Usually sleeps on side or face down in pillow.

    • Possible frequent episodes of waking up during the night.

  • Past medical history may include Acne rosacea, Psoriasis, Hypertension and/or Obstructive sleep apnea.

 

Treatment

  • Use of an eye shield to protect the eyelids during sleep often can improve the patient's signs and symptoms.

  • Pillow case covers made of silk or 300 threads per inch materials can reduce irritation to the eye.

  • Prescription eye ointments and anti-inflammatory medications can help provide relief.

  • Changing sleeping positions or sides can help if the floppy eyelid syndrome is worse in one eye.