Fall 2017 Newsletter

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Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations



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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