The association between eyelid problems and systemic disease is often overlooked. However, this is not the case with floppy eyelid syndrome (FES), which was first described more than 30 years ago by Culbertson and Ostler (1981). The etiology of FES has not been definitively described, although various reports in the literature range from mechanical stress to genetic predisposition.

The former occurs due to spontaneous eversion of the eyelid during sleep. And, due to eyelid laxity, poor apposition between the eyelid and the ocular surface compromises tear film smoothing, leading to signs and symptoms found in FES (Parunović 1983; Swartz et al, 2001; Ezra et al, 2010).

More recently, a genetic predisposition has been postulated that points to abnormalities in collagen and elastin. This theory indicates a connective tissue disorder that may lead to a redundancy of tissue, which would explain the clinical manifestations of FES (Netland et al, 1994; Schlötzer-Schrehardt et al, 2005; Liu et al, 2005). These and other studies have indicated the presence of matrix metalloproteinase enzymes (MMP), especially MMP-7 and MMP-9, and increased levels of serum leptin. MMPs may be responsible for breaking down elastin, while leptin causes an overexpression of MMPs (Taban et al, 2006).

Early on, FES was often attributed to obese men, but other studies indicated a preponderance of women, many of whom were not obese or overweight (Paciuc and Mier, 1982; Muniesa et al, 2013; Hashemi et al, 2016). However, most reports still indicate that the condition is more prevalent in obese patients.

FES is also highly associated with obstructive sleep apnea (OSA) and appears more prevalent as the severity of the OSA increases (McNab, 1997; McNab, 2005; Karger et al, 2006; Chambe et al, 2011; and others. Full list available at .). A recent meta-analysis of the association between ophthalmic disease and OSA found that OSA patients, when compared to non-OSA patients, had an increased risk of FES (OR= 4.2) and glaucoma (OR=1.2); the authors suggested screening for OSA in FES and glaucoma patients (Huon et al, 2016). Sometimes FES may be more evident on the eyelid that coincides with the side on which the patient sleeps. A diagnosis of FES should necessitate a referral to the patient’s primary care physician for possible sleep apnea testing.

Clinical manifestations of FES can resemble other ocular surface and adnexal diseases, making diagnosis difficult. Complaints may include non-specific ocular irritation, redness, and eyelid swelling. You may observe a blepharoconjunctivitis, low lid ectropion, hyperkeratotic skin lesions, keratinization of the conjunctiva, and blepharoptosis, leading to confusing the condition with conjunctivitis, blepharitis, or an ocular surface disorder.

The eyelid, especially upper, will take on a rubbery consistency and is everted easily. When manipulating the lids, they will appear unusually pliant, and a lateral displacement of the upper eyelid will demonstrate an abnormal amount of laxity. Another key clinical indicator is lash ptosis, which exhibits downward-turned eyelashes, the severity of which can lead to corneal abrasions (Langford et al, 1998; Sredkova, 2014).

How to Treat

Treatment, which is aimed at protecting the ocular surface, may include taping of the eyelids during sleep, viscous wetting agents before bedtime, and sleep masks. Continued application of lubricants throughout the day may also be useful. Some studies have shown that a continuous positive airway pressure device (CPAP) ameliorating the OSA may also decrease the severity of FES in patients (Acar et al, 2014).

Severe cases of FES that are recalcitrant to more conservative therapies may benefit from surgical intervention (Ezra et al, 2010; Yeung et al, 2014). A recent study has even indicated that oral surgery (palatoplasty), as well as upper airway surgeries, decreased the signs and symptoms of FES (Bayir et al, 2016). However, there are some reports that FES may return after eyelid surgery (Ezra et al, 2010). CLS

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Dr. Miller is an associate dean for academic affairs and professor at the Rosenberg School of Optometry, University of the Incarnate Word. He has received research funding from Alcon and SynergEyes and travel funding from Alcon. You can reach him at