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Case Study: Rubbed the Wrong Way
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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
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