History

• 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

Diagnosis

• 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

Treatment

• 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

References

• 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.

Contact

• J. Bradley Randleman MD, Professor of Clinical Ophthalmology, randlema@usc.edu
• Natasha Naik, MD, PGY-3 Ophthalmology resident, natasha.naik@med.usc.edu

Section Editors

• Vivek Patel, MD, Associate Professor of Clinical Ophthalmology, Program Director, vivek.patel@med.usc.edu
• Jesse Berry, MD, Assistant Professor of Clinical Ophthalmology, Associate Program Director, jesse.berry@med.usc.edu

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