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USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases


Case Study: Rubbed the Wrong Way

Naik Randleman
Presenter: Natasha Naik, MD Discussant: J. Bradley Randleman, MD


  • 72 year-old male with gradually worsening vision over the past year, worse for three months before presentation
  • Glasses no longer helping, difficulty with night vision
  • Patient sleeps on his left side
  • Denies significant eye rubbing, but rubs left eye frequently during the consultation

Exam Findings

  • Mild corneal ectasia of the right eye, severe corneal ectasia of the left eye
  • Normal dilated fundus exam
  • Easily everted eyelids with large bilateral papillae

Differential Diagnosis

  • Keratoconus
  • Pellucid marginal degeneration
  • Post-refractive surgery
  • Previous ocular surgery
  • Contact lens overuse
  • Corneal trauma
  • Corneal ulceration/perforation
  • Mechanical rubbing/floppy eyelid syndrome
  • Blepharitis
  • Allergic/Atopic keratoconjunctivitis
  • Superior limbic keratoconjunctivitis
  • Giant papillary conjunctivitis
  • Ectropion
  • Dermatochalasis

Additional Investigations

  • Corneal topography
  • Pachymetry


  • Floppy eyelid-induced corneal ectasia

Pathophysiology of Floppy Eyelid

  • Decreased elastin -> increased lid laxity
  • Spontaneous eversion of eyelids
  • Chronic inflammation of eyelid and palpebral conjunctiva
  • Mechanical contact/rubbing between conjunctiva and pillow at night
  • Poor apposition of upper eyelid to globe
  • Asymmetric sleeping pattern (one side) frequently results in asymmetric cornea ectasia


  • Control of risk factors
  • Obstructive sleep apnea – sleep study
  • Ocular lubrication
  • Eyelid taping at night
  • Topical or oral antihistamine if allergic component
  • Sleep position and lid hygiene
  • Corneal transplant for severe ectasia
  • Corneal cross-linking for mild-moderate ectasia
  • Consider surgical eyelid tightening procedure

Prognosis and Future Directions

  • Most important treatment approach is control of risk factors and thorough examination of the patient
  • Consider medical and surgical management approaches
  • Eyelid: Combined medial canthopexy and lateral tarsal strip
  • Cornea: Corneal collagen cross-linking failure in a patient with floppy eyelid syndrome
  • Prognosis is good if risk factors and comorbidities are appropriately addressed in a multidisciplinary approach

Figure 1
Figure 1: Pachymetry of the right eye demonstrates diffuse central thinning on overall pachymetry and epithelial map.


Figure 2
Figure 2: Pachymetry of the left eye demonstrates severe inferotemporal thinning on pachymetry and epithelial map.


Figure 3
Figure 3: Topography of the right eye. Central and inferocentral steepening, max K 50.7.


Figure 4
Figure 4: Topography of the left eye. Severe central and temporal steepening, max K 83.1.



  • 2011-2012 Basic and Clinical Science Course, Section 7: Orbit, Eyelids, and Lacrimal System. AAO.
  • Kymionis GD, Grentzelos MA, Liakopoulos DA, Kontadakis GA, StojanovicN. Corneal collagen crosslinking failure in a patient with floppy eyelid syndrome. J Cataract Refract Surg. 2014 Sep;40(9):1558-60.
  • Compton CJ, Melson AT, Clark JD, Shipchandler TZ, Nunery WR, Lee HB. Combined medial canthopexy and lateral tarsal strip for floppy eyelid syndrome. Am J Otolaryngol. 2016 May-Jun;37(3):240-4.
  • Burkat CN, Lemke BN. Acquired lax eyelid syndrome: an unrecognized cause of the chronically irritated eye. Ophthal Plast Reconstr Surg. 2005 Jan;21(1):52-8.
  • Valenzuela AA, Sullivan TJ. Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: a new surgical approach. Ophthal Plast Reconstr Surg. 2005 Jul;21(4):259-63.
  • Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthal Plast Reconstr Surg. 2002;18(5):370-2.


Section Editors


Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel
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