What is Floppy Eyelid Syndrome?
Floppy eyelid syndrome (FES) is a commonly overlooked condition related to the eyelids. With FES, the eyelid is ‘loose’ or ‘floppy’, easily bending out of shape and not bouncing back. Usual symptoms are things like watery eyes, eye irritation, sensitiveness to light and the feeling that something is in your eye. Other signs could be swelling, eye discharge, and redness caused by little bumps on the white of the eye, a condition called papillary conjunctivitis. Despite these recognizable signs and symptoms, floppy eyelid syndrome is not well understood. It was first recognized in 1984, mainly seen in overweight adult men who had floppy eyelids and papillary conjunctivitis.
Some people call it “lax eyelid syndrome” (LES) but that is not exactly correct. LES is a general term for drooping eyelids caused by other known reasons, like damage to the facial nerves (cranial nerve VII palsy), changes in the outer corner of the eye due to age or other non-physical reasons, or physical trauma to the ligaments that support the eyelids. When drooping eyelids occurs as a separate condition not related to other eye surface diseases or papillary conjunctivitis, it is known as “lax eyelid condition” (LAC).
Floppy eyelid syndrome is a specific term used for a group of patients within the broader category of those with LES. It’s mostly seen in middle-aged overweight men who have papillary conjunctivitis. There’s also a strong link between individuals with FES and obstructive sleep apnea, a sleep disorder that results in stopped or shallow breathing during sleep.
So, FES, LES, and LAC are not the same, though they may appear to be similar. To properly identify floppy eyelid syndrome, the medical history and risk factors, time of presentation, and the signs and symptoms should be carefully examined. This attention to detail will assist in correct diagnosis.
What Causes Floppy Eyelid Syndrome?
Floppy eyelid syndrome is a condition where the eyelid is easily turned inside out. There are several theories about what causes this. Culbertson and Ostler believed that it might be due to a loss of elasticity (stretchiness) in a part of the eyelid called the tarsal plate, combined with the inability to fully close the eye during sleep. This could result in the eyelid flipping inside out overnight. Parunovic thought that physical stress could cause an increase in enzymes that breakdown elastic fibers, leading to the eyelid becoming loose.
Schwartz and his team suggested another possible cause. They believed that a poor interaction between the loose eyelids and the surface of the eyeball could cause eyelid injury and looseness. Lastly, multiple research studies have suggested that a protein called elastin might be the main cause of floppy eyelid syndrome. These studies found that not only is the amount of elastin in the tarsal plate decreased, but the elastin fibers are also abnormal.
These traits of abnormal elastin are often seen in conditions that affect the body’s connective tissues, such as Marfan syndrome, Ehlers-Danlos syndrome, and pseudoxanthoma elasticum, among others.
Risk Factors and Frequency for Floppy Eyelid Syndrome
Floppy eyelid syndrome is a condition that affects between 3.5 and 15.8% of the general population. However, this figure could be lower than the real number due to difficulties in diagnosing and defining the syndrome. The data shows that the condition is most common amongst middle-aged men with high body weight. Though, recent research indicates that the occurrence of the syndrome could be similar in women and men. It’s important to note that this condition is not just limited to adults; children can be affected by floppy eyelid syndrome as well.
Signs and Symptoms of Floppy Eyelid Syndrome
People with eye irritations or discomfort may have a variety of symptoms. This can include watering eyes, redness, sensitivity to light, feeling like something is in the eye, sticky eye discharge, dryness, and swollen eyelids. Often, these symptoms might get worse in the morning.
During an eye examination, a doctor may find that the top eyelid can be easily flipped and is loose. Many times, the patient will also have eye inflammation. There are other eye conditions that could be associated with these symptoms including small damage spots on the cornea, inflammation of the cornea, scratches on the cornea, abnormal shaping of the cornea, inflammation of the eyelid, excessive skin folds of the upper eye lid, and improper positioning of the eyelid. Heavily rubbing the eyes is a common habit for people with these conditions.
Please note that the variety of symptoms can include:
- Watering eyes
- Redness
- Sensitivity to light
- Feeling like there’s something in the eye
- Sticky eye discharge
- Dryness
- Swollen eyelids
- Symptoms worsening in the morning
And potential conditions observed during eye examination are:
- Easily flippable and loose top eyelid
- Eye inflammation
- Small damage spots on the cornea
- Inflammation of the cornea
- Scratches on the cornea
- Abnormal shaping of the cornea
- Inflammation of the eyelid
- Excessive skin folds on the upper eyelid
- Improper positioning of the eyelid
- Heavy eye rubbing
Testing for Floppy Eyelid Syndrome
If you have been experiencing chronic irritation and discomfort in your eyes that doesn’t seem to get better with treatment, your doctor may check you for a condition known as floppy eyelid syndrome, or FES. They may also look for signs of sleep breathing disorders such as Obstructive Sleep Apnea (OSA), which are often linked to FES.”
There are different ways of checking for FES. One method involves the doctor pulling up your upper eyelid and measuring how far it moves from its normal position. This is known as McNabb’s approach. A measurement between 15 to 25 mm suggests that you may have floppy eyelids. Another technique, known as the upper horizontal distraction test, measures the distance from the front part of your eyeball to your eyelid when it’s pulled forward. A distance over 17.09 mm is considered significant for FES.
Once FES is diagnosed, your doctor can determine the severity of your condition. They may ask you to look down while your upper eyelid is lifted up. The amount of the inner eyelid (conjunctiva) that can be seen helps to determine the severity of your FES. If no conjunctiva can be seen, you do not have FES. In mild FES, less than one-third of the conjunctiva is visible. If one-third to one-half of the conjunctiva can be seen, that suggests moderate FES. If more than half of the conjunctiva can be seen, then FES is severe.
Another grading method used to determine the severity of FES is based on how much your eyelid can be pulled away from your eyeball. The distance is measured in millimeters and converted into a grading scale of 0 to 4, where 0 indicates no FES and 4 is severe FES.
In addition to these tests, your eyes will be fully examined by the doctor. They may also check for related conditions like keratoconus (a condition in which the clear tissue on the front of your eye bulges outwards) and dry eye. To screen for sleep apnea, the doctor can use the Epworth Sleepiness Scale which assesses your level of daytime tiredness. If your score is greater than 10, a special sleep test called a polysomnography may be needed to confirm a diagnosis of OSA.
Treatment Options for Floppy Eyelid Syndrome
The treatment of floppy eyelid syndrome can be broken down into non-surgical and surgical approaches. The first attempt at management often involves simple solutions. This could include using artificial tears, a special type of eye ointment that patients apply at night, taping the eyelid, and providing a shield for the eye. If the patient has significant eye inflammation, medications that reduce this inflammation may be used.
Another important part of management is addressing any underlying sleep apnea, a sleep disorder that can cause you to stop and start breathing while you sleep. This is typically done using a machine called a Continuous Positive Airway Pressure machine, or CPAP machine. Proper use of this machine can help improve the eyelid problems and symptoms of dry eyes associated with floppy eyelid syndrome.
If these simpler methods don’t adequately manage the patient’s symptoms, surgery may be considered. There are a variety of surgical procedures available. One of them, called a lateral tarsal strip procedure, helps to shorten the eyelid and decrease its looseness. This procedure was initially used mainly for lower eyelids, but it can now be used for upper eyelids too. Other surgical techniques may include removing a small portion of the eyelid, tightening specific parts of the eyelid support structure, or even simply suturing part of the outer corner of the eye shut.
What else can Floppy Eyelid Syndrome be?
Here are some eye conditions that might be diagnosed:
- Blepharitis: inflammation of the eyelid
- Ectropion: outward turning of the eyelid
- Dermatochalasis: excess, loose skin around the eyelids
- Giant papillary conjunctivitis: red, swollen, itchy eyes due to allergy or irritation
- Atopic keratoconjunctivitis: inflammation of the cornea and conjunctiva due to allergies
- Superior limbic keratoconjunctivitis: inflammation of the upper part of the cornea and the area around it
- Allergic conjunctivitis: inflammation of the eye due to allergies
- Involutional ptosis: drooping of the eyelid with age
- Contact lens complications: issues related to wearing contact lenses
What to expect with Floppy Eyelid Syndrome
When treated, Floppy Eyelid Syndrome (FES) is a condition that can be managed well with a small risk of complications. If FES is not treated, it may lead to more serious eye conditions, such as dry eye and other diseases that affect the surface of your eye. People who have both Obstructive Sleep Apnea (OSA – a sleep disorder where breathing stops and starts) and FES have noticed an improvement in both conditions after treatment.
Some studies have shown that people who consistently used a Continuous Positive Airway Pressure (CPAP) therapy device – a treatment commonly used for OSA – experienced complete clearing up of FES.
However, not all patients respond to simpler treatment approaches for FES and might need corrective surgery. For patients who have a lateral tarsal strip procedure (a surgical technique used to tighten the upper or lower eyelid), studies have shown that up to 91% of patients reported better symptoms and up to 98% of patients had long-term success. Other surgical procedures, such as full and modified full-thickness wedge excision (removing a full or modified full piece of wedge-shaped tissue) and canthal tendon plication (tightening the tendon in the corner of the eye), have shown similarly successful results.
Recently, however, studies suggest that long-term results are better for patients who undergo medial and lateral canthal plication (tightening the tendon from the inside and outside corner of the eye) over full-thickness wedge excision.
Possible Complications When Diagnosed with Floppy Eyelid Syndrome
If FES (Floppy Eyelid Syndrome) isn’t treated, it can cause ongoing irritation and inflammation of the eye surface. Symptoms may include keratitis (inflammation of the cornea), repeated corneal erosions (scratches on the cornea), and in some instances, blood vessels and scars can form on the cornea. In serious cases, there may even be ulcers or holes in the cornea.
Common Symptoms:
- Ongoing eye surface irritation and inflammation
- Keratitis (inflammation of the cornea)
- Repeated corneal erosions (scratches on the cornea)
- Formation of blood vessels and scarring on the cornea
- Corneal ulcers
- Holes in the cornea
Preventing Floppy Eyelid Syndrome
The chances of a successful recovery could be improved if patients follow certain suggestions:
* It’s advised not to rub your eyelids, as this action can make the looseness of the eyelid worse.
* Carefully follow your treatment plan, which may involve using skin creams, eyelid protectors, and taping your eyelid at night to ensure it remains closed and heals properly.
* Try to maintain a sleeping position that doesn’t disturb your eyelid during the night. Ideally, avoid sleeping on your side or with your face down on the pillow.
* If prescribed a CPAP (Continuous Positive Airway Pressure) machine to help with a condition called sleep apnea, staying consistent with its use could help improve floppy eyelid syndrome. Sleep apnea is a condition where a person’s breathing repeatedly stops and starts during sleep, and a CPAP machine helps to keep the airway open and improve breathing.
