Floppy Eyelid Syndrome


  • A relatively uncommon condition characterized by loose, easily everted upper eyelids. Floppy eyelid syndrome (FES) is often seen in overweight, middle-aged males. Some of these patients also suffer from obstructive sleep apnea (OSA).
  • Treatment for FES often includes artificial tears to reduce irritation and an antibiotic if signs of infection are present. Using tape or an eyeshield to keep {the} eyelids closed while sleeping might help prevent lid eversion and keep {the} eyes from becoming dry
  • Symptoms generally consist of ocular injection, irritation, itching and stringy mucous discharge, particularly upon awakening. The symptoms might appear unilaterally or asymmetrically. Patients with OSA might also complain of erratic sleep patterns, chronic somnolence and morning headaches
  • Examination of patients with FES typically reveals chronic papillary conjunctivitis with mild to moderate bulbar hyperemia, often lateralizing to {the} patient's habitual sleeping side (i.e., if they sleep on their left side, {the} presentation is more evident O.S.). Punctate corneal epitheliopathy and mucous strands in {the} tear film and fornices might also be apparent. The lids themselves routinely display pseudoptosis and an odd "rubbery" consistency. Eversion of {the} upper lids can be accomplished with minimal manipulation; in fact, it might occur spontaneously during normal ocular examination. Past ocular history might include meibomian gland dysfunction, hordeola or chalazia, keratoconus, and seasonal allergic conjunctivitis




  • The etiology of FES is not thoroughly understood. Research has demonstrated that tarsal elastin is significantly diminished in these patients, such that {the} tarsal plate of {the} eyelid no longer displays its customary rigidity.4 One study suggests that individuals with FES might actually have underlying genetic collagen or elastin abnormalities.5
  • The precise mechanism of this disorder also remains disputed. The most widely held theory suggests that, because of {the} lid laxity and tendency of these patients to lie on their sides or in a "face-down" position, spontaneous lid eversion occurs during sleep. This results in mechanical abrasion of {the} ocular surface. Others have suggested that {the} underlying mechanism is simply poor apposition of {the} upper eyelid to {the} globe, instigating an inadequate tear distribution and subsequent desiccation of {the} ocular surface


  • In {the} majority of cases, diagnosis is made by {the} classic appearance and effortless or spontaneous eversion of {the} eyelids. There are few ancillary tests to consider beyond {the} normal ocular evaluation, though vital dye staining (e.g., sodium fluorescein, rose bengal and/or lissamine green) might help to assess {the} severity of any associated keratopathy.
  • Treatment for FES consists primarily of lubricating {the} ocular surface and safeguarding {the} eye from nocturnal damage. Isotonic artificial tears, used liberally throughout {the} day, help to eliminate mucous debris and promote corneal healing. In cases of moderate or profound epitheliopathy, consider more viscous lubricants such as Systane or Refresh Liquigel on a qid basis. At bedtime, {the} patient should instill either a bland ophthalmic ointment (e.g. Tears Naturale P.M.) or mild antibiotic ointment and apply a protective eye shield, or simply tape {the} lids in a closed position. Substantial, recalcitrant cases that do not respond to primary therapy might require surgical intervention. Most commonly, this involves a lateral eyelid tightening procedure at {the} lateral canthus, or a horizontal lid shortening procedure by full-thickness resection of {the} lateral one-third of {the} lid margin.67 Lateral tarsorrhaphy has been suggested for noncompliant patients with severe disease.
  • As important as managing {the} ocular sequelae of FES is addressing {the} associated problem of obstructive sleep apnea. OSA is a potentially fatal condition that has been linked to pulmonary hypertension, congestive heart failure and cardiac arrhythmia. Weight loss and consultation with a sleep physician for appropriate studies are highly recommended, considering {the} significant comorbidities of both obesity and OSA. At least one study has demonstrated notable improvement of FES when OSA is suitably addressed.



Clinical Pearls

  • Many patients with FES manifest attendant blepharitis, particularly meibomian gland dysfunction. Rosacea has also been found in association with both FES and OSA. Strongly consider a trial of oral doxycycline 100mg bid for six to 12 weeks.
  • When interviewing patients with FES, always remember to inquire about prominent snoring or gasping episodes during sleep. In this regard, realize that a spouse or family member might actually prove to be a more reliable resource than {the} patient! Any such findings consistent with OSA warrant consultation with a sleep physician, otolaryngologist or pulmonologist.


McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg 1997;13(2):98-114. Mojon DS, Goldblum D, Fleischhauer J, et al. Eyelid, conjunctival, and corneal findings in sleep apnea syndrome. Ophthalmology 1999;106(6):1182-5. Robert PY, Adenis JP, Tapie P, et al. Eyelid hyperlaxity and obstructive sleep apnea (O.S.A.) syndrome. Eur J Ophthalmol 1997;7(3):211-5. Netland PA, Sugrue SP, Albert DM, et al. Histopathologic features of {the} floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology 1994; 10(1)1:174-81. Lee WJ, Kim JC, Shyn KH. Clinical evaluation of corneal diseases associated with floppy eyelid syndrome. Kor J Ophthalmol 1996;10(2):116-21. Periman LM, Sires BS. Floppy eyelid syndrome: A modified surgical technique. Ophthal Plast Reconstr Surg 2002;18(5):370-2. Bouchard CS. Lateral tarsorrhaphy for a noncompliant patient with floppy eyelid syndrome. Am J Ophthalmol 1992;114(3):367-9. McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea. Clin Experiment Ophthalmol 2000;28(2):125-6.

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