Case Study: Rubbed the Wrong Way
Presenter: Natasha Naik, MD
Discussant: J. Bradley Randleman, MD
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
Figure 1: Pachymetry of the right eye demonstrates diffuse central thinning on overall pachymetry and epithelial map.
Figure 2: Pachymetry of the left eye demonstrates severe inferotemporal thinning on pachymetry and epithelial map.
Figure 3: Topography of the right eye. Central and inferocentral steepening, max K 50.7.
Figure 4: Topography of the left eye. Severe central and temporal steepening, max K 83.1.
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
Section Editors
Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel