Surgical management of floppy eyelid syndrome

Effects of full-thickness wedge resection on ocular surface and in vivo confocal microscopy findings in floppy eyelid syndrome patients

OBJECTIVE

To evaluate the effect of full-thickness wedge resection (FTWR) on ocular surface and in vivo confocal microscopy (IVCM) findings in patients with floppy eyelid syndrome (FES).

METHODS

The study included two groups: a surgical treatment (ST) group (26 eyes) consisting of patients who underwent FTWR surgery, and a conservative treatment (CT) group (30 eyes). Pre-treatment and post-treatment ocular surface disease index (OSDI), tear break-up time (TBUT), corneal fluorescein staining (CFS), IVCM findings along with the body mass index (BMI), FES grade, the presence and the treatment of obstructive sleep apnea syndrome (OSAS) were recorded and compared between the groups.

RESULTS

The groups were comparable in terms of BMI, FES grade, and OSAS data. After six months, TBUT in the ST group significantly increased to 12.92 ± 1.15, compared to 8.10 ± 1.60 in the CT group (p = 0.000). The CFS and OSDI scores were significantly lower in the ST group (0.15 ± 0.37, 18.0 ± 8.3, respectively) compared to the CT group (0.90 ± 0.61, 27.3 ± 9.3, respectively) (p = 0.000). IVCM analysis revealed a significant decrease in dendritic cell count (ST: 22.0 ± 12.4, CT: 39.5 ± 15.1, p = 0.000) and nerve tortuosity (ST: 1.38 ± 0.64, CT: 2.00 ± 0.59, p = 0.000), with a significant increase in total nerve density (ST: 4.27 ± 0.83, CT: 3.57 ± 0.90, p = 0.002) in the ST group compared to the CT group after six months.

CONCLUSION

In our retrospective cohort, FTWR surgery was shown to be an effective and reliable surgical treatment for FES, improving both ocular surface and IVCM findings. Patients with moderate to severe stages of FES not responding to conservative treatment may benefit from eyelid tightening.

Prevalence of Obstructive Sleep Apnea With Floppy Eyelid Syndrome: A Systematic Review and Meta-analysis

PURPOSE

This study investigated the prevalence of obstructive sleep apnea (OSA) in floppy eyelid syndrome (FES) patients and evaluated the severity of OSA with FES prevalence.

METHODS

Cochrane CENTRAL, Medline, Science Direct, Google Scholar, and PubMed databases were searched for studies on FES patients and its association with OSA syndrome, of any design, published from January 1, 1997, to January 1, 2022. A random-effects model that weighted the studies was used when there was heterogeneity between studies ( p < 0.10) and if I 2 values were more than 50%. All p values were 2-tailed and considered statistically significant if <0.05.

RESULTS

A total of 12 studies comprising 511 patients were included in this meta-analysis. Of these, 368 were male (77.6%) and the average age was 55.10 years. The overall prevalence of OSA in FES patients was 57.1% (95% CI: 46.5-74.8%), M:F ratio was 48:1 (98% male), and 69.1% of patients received their OSA diagnosis at the time of the study. Of those with FES, tear film abnormalities were the most common ocular comorbidity (78.9%) followed by keratoconus (20.6%), glaucoma (9.8%), and lower eyelid ectropion (4.6%). Obesity was the most common systemic morbidity (43.7%) followed by hypertension (34.0%) and diabetes mellitus (17.9%).

CONCLUSION

This meta-analysis demonstrates OSA is a common comorbidity in the FES population. Ophthalmologists are often the first to evaluate patients with FES, and considering this coincidence, routine screens for sleep apnea symptoms in at-risk FES patients should be undertaken. Large case-control studies are required to better elucidate the exact prevalence of OSA and other morbidities in patients with FES, and to better understand the etiology of FES.

Floppy eyelid, an under-diagnosed syndrome: a review of demographics, pathogenesis, and treatment

Floppy eyelid syndrome (FES) is a frequent eyelid disorder characterized by eyelid laxity that determines a spontaneous eyelid eversion during sleep associated with chronic papillary conjunctivitis and systemic diseases. FES is an under-diagnosed syndrome for the inaccuracy of definition and the lack of diagnostic criteria. Eyelid laxity can result from a number of involutional, local, and systemic diseases. Thus, it is pivotal to use the right terminology. When the increased distractibility of the upper or lower eyelid is an isolated condition, it is defined as ‘lax eyelid condition’ (LAC). When laxity is associated with ocular surface disorder such as papillary conjunctivitis and dry eyes, it can be referred to as ‘lax eyelid syndrome’ (LES). However, FES is characterized by the finding of a very loose upper eyelid which everts very easily and papillary tarsal conjunctivitis affecting a specific population of patients, typically male, of middle age and overweight. Obesity in middle-aged male is also recognized as the strongest risk factor in obstructive sleep apnea-hypopnea syndrome, (OSAHS). FES has been reported as the most frequent ocular disorder associated with OSAHS. Patients with FES often complain of non-pathognomonic ocular signs and symptoms such as pain, foreign body sensation, redness, photophobia, and lacrimation. Due to these clinical features, FES is often misdiagnosed while an early recognition might be important to avoid its chronic, distressing course and the associated morbidities. This review provides an updated overview on FES by describing the epidemiology, proposed pathogenesis, clinical manifestations, related ocular, and systemic diseases, and treatment options.

The prevalence of anophthalmic socket syndrome and its relation to patient quality of life

BACKGROUND

Following removal of the eye, soft tissue changes of the eyelids and orbit may develop into an anophthalmic socket (AS) syndrome, which is often attributed to orbital volume deficiency. While adequate primary orbital volume replacement is nowadays standard of care, patients may still present with facial asymmetry. The aim of this study is to provide insights into these changes and their impact on patient quality of life (QoL).

METHODS

Cross-sectional study of 59 patients with longstanding ocular prosthetic wear after enucleation or evisceration surgery. The alignment, function, and laxity of the eyelids of the anophthalmic side were compared to those of the fellow side. The QoL was assessed with a 4-item questionnaire specific for the prosthetic condition. The different aspects of AS syndrome were analysed in relation to disease-specific and prosthetic data and to the patient QoL scores.

RESULTS

Clinical AS syndrome was prevalent in 53% of patients with acquired anophthalmia. The anophthalmic side was statistically significantly different from the fellow side for the known AS syndrome features such as superior sulcus depression, margin reflex distance 1, and enophthalmia, but also for new features such as levator muscle function and lagophthalmia (P < 0.05). The difference was correlated with duration of prosthetic wear, prior orbital radiotherapy, and size of the prosthesis (P < 0.05). QoL scores were not correlated to the separate features of AS syndrome, except for a positive correlation between wearing comfort of the prosthesis and upper eyelid ptosis (P < 0.05).

CONCLUSION

Patients with an ocular prosthesis show a relatively high prevalence of one or more distinct clinical features of AS syndrome, which do not negatively affect patient QoL. These findings underscore the importance to tailor prosthetic and surgical treatment to the patient's perceived QoL rather than to the objective clinical findings.

Photochemical Collagen Cross-Linking Reverses Elastase-Induced Mechanical Degradation of Upper Eyelid Tarsus

INTRODUCTION

The floppy eyelid syndrome describes an eyelid disorder characterized by floppy tarsal plates that may be caused by a loss of elastin. The authors attempted to create floppy eyelids by digesting elastin from cadaveric tarsus and then treated them with cross-linking using ultraviolet A and riboflavin.

METHODS

Nine right and 9 left upper eyelids were excised from cadavers. Four vertical strips of central tarsus were removed from each eyelid. One strip of tarsus from each eyelid was treated with 10 units/ml of elastase for 2 hours. Another tarsal strip from each eyelid was immersed in normal saline for 2 hours (control). A third strip from the same eyelid was cross-linked using ultraviolet A at 6 mW/cm for 18 minutes. Finally, a fourth strip of tarsus was cross-linked in the same manner following treatment with elastase for 2 hours. A microtensile load cell was used to measure the Young modulus (stiffness) of each tissue.

RESULTS

Mean (standard deviation) Young modulus for controls (18.9 ± 3.6 MPa) was significantly higher than samples treated with elastase alone (6.6 ± 3.8 MPa, p <0.01). Samples that were treated with cross-linking after elastase had a mean (standard deviation) Young modulus of 26 ± 2.3 MPa, while those treated with cross-linking alone had a mean (standard deviation) Young modulus of 34 ± 0.15 MPa. The differences in stiffness between all groups were significant (p <0.01).

DISCUSSION

Treatment with elastase significantly reduces the stiffness of tarsal plates. This effect is reversed by cross-linking, raising the possibility of using this modality for the treatment of FES.

Canthal V-plasty for Floppy Eyelid Surgery

Supplemental Digital Content is available in the text.

The purpose of this article is to present a modified approach to the reconstruction of the upper and lower eyelids in floppy eyelid syndrome. A retrospective chart review was performed on all floppy eyelid patients who underwent simultaneous tightening of the upper and lower eyelid with a lateral tarsal strip, using a V-shaped incision in the lateral canthus, at University of Tennessee Hamilton Eye Institute from 2011 to 2012. Preoperative symptoms, surgical outcomes, complication rates, and postoperative symptoms were recorded. Nine eyes of 7 patients who underwent surgical correction for symptomatic floppy eyelids were included. All patients noted improvement in symptoms postoperatively, after reduction in the laxity of the upper and lower eyelid. Postoperative complications included buried lashes in the lateral canthus in 1 eye and a pyogenic granuloma in the lateral canthus of 1 eye. An excellent cosmetic outcome was noted in 78% (7/9) of eyes. No patients reported dissatisfaction nor required secondary surgical correction. The lateral canthal “V” incision provides an additional approach in the successful management of floppy eyelid syndrome involving the upper and lower eyelids. The design of the incision allows for excellent exposure of the lateral canthus for shortening of the eyelids with tarsal strip fixation, and it preserves the lateral canthal skin and canthus architecture. Further, the “V” incision is easily continued into the eyelid crease for blepharoplasty and ptosis repair when necessary.

[Floppy eyelid syndrome : A frequently underdiagnosed entity of interdisciplinary importance]

Clinically, the floppy eyelid syndrome is a frequent but underdiagnosed condition. This clinical phenotype is characterized by an extreme laxity of the eyelid, which is enlarged and has a rubber-like structure in combination with a pronounced hyperelastic tarsus. When looking down, minimal vertical tension can trigger spontaneous eversion of the upper eyelid leading to chronic papillary conjunctivitis. This syndrome usually affects older, adipose men who also suffer from sleep apnea and metabolic syndrome. Due to the resistance of chronic papillary conjunctivitis to conservative treatment, surgical treatment is often necessary; however, due to the frequent association between floppy eyelid syndrome, sleep apnea and metabolic syndrome a collaborative interdisciplinary approach is necessary.

Floppy eyelid syndrome: A comprehensive review

Floppy eyelid syndrome (FES) is defined as eyelid hyperlaxity with reactive palpebral conjunctivitis. It is a common condition that can be associated with significant ocular irritation. FES presents with easily everted eyelids and chronic papillary conjunctivitis in the upper eyelids. It is frequently associated with ocular and systemic diseases, notably keratoconus and obstructive sleep apnea, respectively. This comprehensive review describes the epidemiology, pathological changes, proposed pathogenesis, clinical manifestations, and a variety of treatment options for this condition. Conservative treatment of FES includes aggressive lubrication, nighttime eye shield, and avoiding sleeping on the affected eye. Patients with FES and obstructive sleep apnea may have an improvement in their ocular signs and symptoms after long-term therapy with continuous positive airway pressure. In refractory cases, a corrective surgery that addresses the eyelid laxity can result in significant improvement. All patients with ocular irritation should be evaluated for the presence of FES.

Floppy eyelid syndrome "plasty" procedure: Employment of a periosteal transposition flap for surgery of floppy eyelid syndrome

IMPORTANCE

Floppy eyelid syndrome "plasty" (FESplasty) is a surgical technique that addresses underlying superior tarsal plate and lateral canthal instability in floppy eyelid syndrome (FES) and aims to restore normal anatomical and physiological function to the upper eyelid.

BACKGROUND

To describe the use of FESplasty in the surgical management of FES, and to report outcomes in an initial patient cohort.

DESIGN

Retrospective study.

PARTICIPANTS

Seven patients (nine eyelids) with FES undergoing FESplasty.

METHODS

A single surgeon (G.W.) performed all procedures. FESplasty utilizes a periosteal flap based at the inferolateral orbital rim, and applied to the anterior surface of the upper tarsal plate. It is combined with a titrated shortening procedure of the upper eyelid. Patient demographics, comorbidities and ocular symptoms and signs were recorded preoperatively. Pre- and postoperative upper eyelid distractibility were graded and documented.

MAIN OUTCOME MEASURES

Postoperative improvement in upper eyelid distractibility and symptomatology, operative complications and FES recurrence.

RESULTS

FES symptoms and upper eyelid laxity improved at last follow-up (average 24 weeks) in all patients, with no FES recurrences after a maximum follow-up of 36 weeks. One patient, in whom FESplasty exacerbated his pre-existing aponeurotic ptosis, required definitive ptosis surgery subsequently. There was one case of postoperative wound infection. Obstructive sleep apnoea was present in four of the seven patients. The remaining three patients were awaiting assessment.

CONCLUSIONS AND RELEVANCE

FESplasty is likely to confer long-term effective stabilization of the lateral canthal tendon, lateral commissure and superior tarsal plate. Anatomical and functional results appeared to have been successfully achieved.

Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions

Aponeurotic ptosis accounts for the majority of acquired ptosis encountered in clinical practice. Other types of ptosis include traumatic, mechanical, neurogenic, and myogenic. In addition to true ptosis, some patients present with pseudoptosis caused by globe dystopia, globe asymmetry, ocular misalignment, or retraction of the contralateral lid. It is particularly important for the clinician to rule out neurologic causes of ptosis such as dysfunction of the third cranial nerve, Horner's syndrome, and myasthenia gravis, as these conditions can be associated with significant systemic morbidity and mortality. A thorough history and physical examination is necessary to evaluate each patient presenting with a complaint of ptosis. Correctly identifying the cause of the patient's complaint allows the ptosis surgeon to plan for appropriate surgical repair when indicated and to defer surgery when observation or additional clinical evaluation is warranted.

Combined medial canthopexy and lateral tarsal strip for floppy eyelid syndrome

PURPOSE

To describe the eyelid condition known as "floppy eyelid syndrome" and to present the results of our experience treating patients with floppy eyelid syndrome.

METHODS

A retrospective analysis of 16 patients from 2009 to 2013 who underwent combined medial canthopexy and lateral tarsal strip by two surgeons (HBL and WRN) for the treatment of floppy eyelid syndrome (FES). Age, gender, presence of obstructive sleep apnea (OSA), papillary conjunctivitis, punctate keratopathy and lash ptosis were recorded pre-operatively. Outcomes assessed included improvement in upper eyelid laxity, operative complications, post-operative symptomatic relief and delayed recurrence of FES.

RESULTS

A total of 18 procedures (on 36 eyelids) were performed on 16 patients over the 4-year period. All patients (18/18) had relief of symptoms and good functional results, defined as improvement in lid laxity and resolution of symptoms. Average follow up was 124days. 8 of 16 patients (50%) had a pre-existing diagnosis of OSA. The remaining 8 patients were referred for sleep study and 2 were subsequently diagnosed with OSA. Two patients experienced some degree of FES recurrence without return of symptoms. There was one complication reported in which a partial dehiscence of the lateral canthal tendon occurred which did not require operative revision.

CONCLUSIONS

Combined medial canthopexy and lateral tarsal strip are a safe and effective technique for the treatment of floppy eyelid syndrome. There is a strong association of FES and OSA and it is important to have any patient diagnosed with FES evaluated for OSA.

Floppy eyelid syndrome: the coventry experience

PURPOSE

Floppy eyelid syndrome is a condition that is difficult to identify and diagnose and with no clear guidelines on its management. We propose a method of reliably grading this syndrome and have proposed a management algorithm based on the grading.

MATERIALS AND METHODS

Retrospective data collection of patients diagnosed with Floppy eyelid syndrome and treated under the care of a single oculoplastic surgeon over a 9 year period.

RESULTS

First, 102 patients were included and were classified into 3 groups. Grade 1 (F1) 7.5%, Grade 2 (F2) 36.5% and Grade 3 (F3) 56%. Only 12% of our cohort required surgery, and 92% of these patients demonstrated improvement in their symptoms.

DISCUSSION

Clinical grading of Floppy eyelid syndrome patients will help determine patient's management plan. In our experience, operating on both upper and lower eyelids at the same time where indicated helps to maintain the normal anatomical relationship and improve epiphora.

Ocular surface assessment in patients with obstructive sleep apnea-hypopnea syndrome

PURPOSE

The aim of this study was to assess the correlation between ocular surface changes and disease severity in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS).

METHODS

Two hundred eighty patients with OSAHS were compared with respect to the presence of a floppy eyelid syndrome (FES), Ocular Surface Disease Index (OSDI) questionnaire, the corneal fluorescein staining stages, the Schirmer I test, and tear film break-up time (TBUT) values.

RESULTS

Based on the apnea-hypopnea index, the presence of FES was detected at the following rates: 23.1 % in non-OSAHS group (A), 41.7 % in mild group (B), 66.7 % in moderate group (C), and 74.6 % in severe group (D); severe and moderate stage of FES was found in groups C and D and mild stage of FES in group B (p < 0.01). OSDI questionnaire values were as follows: group A, 12.57 ± 17.64; group B, 22.90 ± 16.78; group C, 45.94 ± 22.03; and group D, 56.68 ± 22.85(p < 0.01). Schirmer values were as follows: group A, 10.76 ± 3.58 mm; group B, 9.83 ± 2.53 mm; group C, 7.73 ± 2.42 mm; and group D, 6.97 ± 2.15 mm (p < 0.01). The TBUT values were as follows: group A, 10.53 ± 3.64 s; group B, 9.46 ± 2.40 s; group C, 7.29 ± 2.13 s; and group D, 6.82 ± 2.20 s (p < 0.01). Corneal staining scores are as follows: 0.26 ± 0.60 in group A, 0.40 ± 0.71 in group B, 0.98 ± 0.72 in group C, and 1.14 ± 0.90 in group D, and the differences were statistically significant among the groups(p < 0.01).

DISCUSSION

OSAHS, particularly the moderate and severe forms, is associated with low Schirmer and TBUT values and high scores in OSDI questionnaire and corneal staining pattern stage. The presence of FES is observed as a practically constant finding in OSAHS. If complaints such as burning, stinging, and itching which can be commonly observed in middle-aged patients are accompanied by FES, the patient should be evaluated for sleep disorders. We speculate that appropriate treatment of OSAHS may result in better control of these symptoms.

Floppy eyelid syndrome as a subset of lax eyelid conditions: relationships and clinical relevance (an ASOPRS thesis)

PURPOSE

To better define the wide spectrum of lax eyelid conditions, especially the subtype referred to as floppy eyelid syndrome, and to clarify its relationship with associated ophthalmic findings.

METHODS

A case-based retrospective review of all patients seen at UNC Department of Ophthalmology with a diagnosis of floppy eyelid syndrome or lax upper eyelid was performed. The period of review was from March 2002 to March 2007. A literature review was also performed using the term "floppy eyelid syndrome" and "lax eyelid syndrome" as the keywords in a PubMed search. Charts and cases were reviewed for the following information: age, sex, presence or absence of obesity, presence or absence of upper eyelid laxity, presence or absence of lower eyelid laxity, symmetry or asymmetry of eyelid laxity, sleeping position preference, diagnosis of obstructive sleep apnea (OSA), history of eye rubbing, diagnosis of keratoconus (KCN), lash ptosis, history of spontaneous eyelid eversion, papillary conjunctivitis, systemic hyperlaxity, diagnosis of meibomianitis, signs of anterior segment inflammation, and smoking or excessive sun exposure history.

RESULTS

From our UNC case review, 14 patients involving 17 eyelids were identified. From the literature review, 72 articles were recovered and evaluated to yield a total of 324 reported cases through February 2007. From the combined data (n = 338), the overall minimum prevalence of sleep apnea in patients with lax eyelid condition was 16% compared with an estimated 9% to 24% in the general population. Of patients with lax eyelid syndrome, those identified with OSA had significantly more individuals with obesity (76% vs. 20%) and male gender (89% vs. 61%) than the group without OSA. The prevalence of KCN in patients with lax eyelid syndrome was a minimum of 6.8%, which is considerably higher than the estimated prevalence in the general population of 0.6%. However, KCN appears to show a significant association with the patient's side of sleeping preference.

CONCLUSIONS

Eyelid laxity can result from a number of involutional, local, and systemic diseases but is frequently of unknown etiology. When it is consistently associated with papillary conjunctivitis and dry eyes it can be referred to as lax eyelid syndrome (LES). A number of specific subsets of LES can be identified. One such subset, occurring primarily though not exclusively in males and associated with obesity, has been defined as the floppy eyelid syndrome (FES). OSA has been associated with FES where it occurs with greater frequency than in the general population, but no greater than seen in obese males without FES, and therefore appears to represent an epiphonomenom only. However, given the demographics of FES, this condition offers some predictive value for OSA and should alert the physician to evaluate the sleep habits of all such patients. Keratoconus also shows some association with FES and with LES. However, data suggest that the causative factors are sleep preference for the involved side and nocturnal eyelid eversion, rather than any underlying physiologic or anatomic relationship.

Floppy Eyelid Syndrome

PURPOSE

To evaluate the change in upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

Eighteen patients with a clinical diagnosis of floppy eyelid syndrome.

METHODS

Horizontal surgical tightening of the upper eyelid was performed by full-thickness wedge resection in 24 eyelids of 18 patients with floppy eyelid syndrome. Preoperative and postoperative upper eyelid position as measured by the margin reflex distance (MRD) was assessed. Student's paired t test then was used to analyze the change in upper eyelid position after horizontal tightening alone of floppy upper eyelids.

MAIN OUTCOME MEASURES

Change in upper eyelid MRD after surgery.

RESULTS

Preoperative MRD ranged from -0.5 to 4.0 mm, with a mean of 1.9 mm (+/-1.3 mm, standard deviation [SD]). Postoperative MRD ranged from 0.5 to 6.0 mm, with a mean of 3.2 mm (+/-1.4 mm, SD). The change in MRD ranged from -0.5 to 2.5 mm, with a mean of 1.3 mm (+/-0.7 mm, SD; P<0.001).

CONCLUSIONS

Horizontal upper eyelid tightening alone generally results in secondary improvement of the ptosis associated with floppy eyelid syndrome.

Floppy eyelid syndrome

PURPOSE OF REVIEW

Although floppy eyelid syndrome causes significant ocular symptoms and morbidity, the condition is often underdiagnosed. This review will highlight diagnostic features of the condition, emphasizing recent advances in the understanding of its pathophysiology. Current therapeutic strategies and surgical techniques are discussed.

RECENT FINDINGS

Current concepts regarding the underlying pathophysiology of floppy eyelid syndrome revolve around upregulation of elastin degrading enzymes and mechanical factors. Together, these forces cause instability of the eyelid scaffold, resulting in eyelid malposition and ocular symptoms. Newer surgical treatments aim to preserve tarsus to improve eyelid stability and position.

SUMMARY

Floppy eyelid syndrome--an underdiagnosed condition--produces significant ocular morbidity. Symptoms range from occasional redness and irritation to corneal ulcer. Diagnosis is based on ocular signs, including easy or spontaneous eversion of the upper eyelids in conjunction with conjunctivitis and keratitis. The condition, associated with body mass index and obstructive sleep apnea, should be suspected in any obese patient with a chronic red and tearing eye. Treatment consists of supportive measures such as ocular lubrication, eyelid taping or a shield, and surgery to address horizontal laxity and redundant eyelid tissues.

Medial Upper Eyelid Shortening to Correct Medial Eyelid Laxity in Floppy Eyelid Syndrome: A New Surgical Approach

PURPOSE

To describe and present the results of a new surgical technique for patients with floppy eyelid syndrome, based on the medial upper eyelid stretching encountered in this condition.

METHODS

A case series of 24 patients with floppy eyelid syndrome who where found to have symptomatic predominately medial upper eyelid laxity was analyzed. The history, clinical features, histopathology, and outcome were reviewed after patients underwent medial upper eyelid shortening with or without upper eyelid skin reduction as the first surgical procedure.

RESULTS

Of the 24 patients, 18 were men (75%) with a mean age at referral of 56 years, having ocular discomfort and conjunctival irritation/papillary conjunctivitis as the main complaints at presentation. Obesity was present in 96% of cases, with lower eyelid laxity/ectropion (50%) and upper eyelid eyelash ptosis (29%) in conjunction with the upper eyelid laxity. The affected side was related to sleeping habits or recurrent mechanical eyelid trauma. Histologic studies showed a nonspecific inflammatory cell infiltrate and loss of elastin with loose dermal connective tissue. After surgery, complete relief of ocular symptoms and good functional and cosmetic results were present in all cases after 18 months of follow-up.

CONCLUSIONS

This new surgical approach is based on the presence of predominately medial upper laxity in patients with floppy eyelid syndrome. The excision of this stretched area stabilized the upper eyelid in an anatomic fashion, providing a good and stable long-term result. The possible mechanisms involved in the medial upper eyelid stretching are discussed.

Acquired Lax Eyelid Syndrome

PURPOSE

To describe the demographics, symptoms, and findings of acquired lax eyelid syndrome and to assess the efficacy of the 4-eyelid tarsal strip-periosteal flap technique to treat horizontally lax upper and lower eyelids.

METHODS

A retrospective, case-series review of 80 patients (320 eyelids) evaluated from January 2000 to April 2004 for lax upper and lower eyelids causing chronic irritation was performed. Ten patients with diagnosed floppy eyelid syndrome or obstructive sleep apnea were excluded. Height and weight of all patients were recorded to calculate body mass index. Lateral tarsal strip fixation of all 4 eyelids to periosteal flaps based inside the orbital rim was performed to achieve horizontal tightening. Postoperative follow-up ranged up to 52 months. Preoperative/postoperative symptoms and examination findings of upper and lower eyelid distraction, keratopathy, and conjunctival inflammation were compared.

RESULTS

The most common presenting symptoms were epiphora (85.7%) and irritation (80%). The most common examination findings were upper and lower eyelid horizontal laxity and palpebral conjunctival injection (100% patients). Thirteen of 70 patients (18.6%) were obese, based on body mass index; 26 of 70 patients (37.1%) were mildly overweight; 29 of 70 patients (41.4%) were normal weight; and 2 of 70 patients (2.9%) were underweight. After surgery, 91% of patients had improved or resolved symptoms and signs; 2.5% of dehiscences occurred with the use of the 4-eyelid technique. Gradual continued improvement was observed for up to 1 year.

CONCLUSIONS

Evaluation of patients presenting with chronically irritated eyes should include distraction of both the upper and lower eyelids and examination for conjunctival inflammation. Acquired lax eyelid syndrome is similar to floppy eyelid syndrome; however, 43.3% of patients were normal weight or underweight. The 4-eyelid tarsal strip-periosteal flap fixation is a rapid and effective technique for correction of this syndrome.

Anophthalmic Ptosis: Investigation of the Mechanisms and Statistical Analysis

PURPOSE

To investigate the mechanisms producing ptosis in anophthalmic patients by comparing potential risk factors among patients with ptosis with a control group. Specific techniques for achieving optimal aesthetic results in the surgical correction of anophthalmic ptosis are recommended.

METHODS

Data from 94 anophthalmic patients with ptosis and 44 control patients without ptosis were retrospectively collected and analyzed. Potential risk factors for ptosis were compared between the two groups of patients by using 2-sample binomial exact tests. Univariate and multivariate logistic regression analyses were also used.

RESULTS

A direct relation between percent volume replacement by the primary implant and the occurrence of ptosis was noted (P=0.057; age adjusted, P=0.037). Those patients who had secondary implant surgery were more likely to have levator surgery for ptosis (P=0.005; age adjusted, P=0.039). A greater number of years of prosthesis wear was associated with clinical and intraoperative evidence of levator dehiscence (P=0.061). No relation was observed between the occurrence of trauma (as a reason for enucleation) and the occurrence of levator dehiscence. Thirty percent of patients with ptosis who had secondary intraconal or extraconal implants and no other surgical intervention for ptosis had improvement in ptosis.

CONCLUSIONS

The mechanisms producing anophthalmic ptosis should be assessed carefully before surgical repair to achieve optimal aesthetic results. Correction of volume deficiency should be offered before levator surgery for patients with anophthalmic ptosis. The patient should be advised that tilt of the prosthesis is a possible outcome of levator repair and may reflect overcorrection or insufficient volume replacement.

Lateral tarsorrhaphy for prevention of postoperative complications resulting from globe luxation

We present a case of spontaneous globe luxation and wound dehiscence that developed in a patient with proptosis 1 day after phacoemulsification with posterior chamber intraocular lens implantation. The wound was repaired and a lateral tarsorrhaphy was performed with successful prevention of further luxations. Upon cataract extraction in the patient's other eye, lateral tarsorrhaphy was performed concurrently to prevent operative complications. This report underscores the importance of lateral tarsorrhaphy performed at the time of cataract surgery to avoid postoperative globe luxation with possible wound dehiscence in patients with proptosis or shallow orbits and a history of luxation.

Floppy eyelid syndrome: a modified surgical technique

PURPOSE

To describe and present the results of a modified surgical technique to repair floppy eyelids.

METHODS

A case series of 5 patients who were treated with the modified technique is presented. This technique uses the relaxed skin tension lines to tighten the lids in an aesthetically minded reconstruction.

RESULTS

All patients had relief of symptoms and good cosmetic and functional results. Average follow-up was 39 months. Complications were minor and easily treated.

CONCLUSIONS

This modified surgical technique provides excellent long-term structural integrity of the wound with a potentially more acceptable camouflaged scar.

Surgical management of seventh nerve paralysis and floppy eyelid syndrome

A seven-stage approach to the management of the paretic eyelid complex has been described. These stages include supportive care, planning and execution of general facial reanimation, lower eyelid and canthal resuspension or support, passive upper eyelid animation, dynamic lid animation, and soft tissue repositioning. A final stage, the epilogue, is described for the treatment of the synkinesis and hypertonicity that often develop. Recent developments in these areas are discussed. Floppy eyelid syndrome, first described by Culbertson and Ostler, is a syndrome of chronic papillary conjunctivitis in overweight patients with easily everted eyelids. The syndrome has now been associated with a variety of other conditions and findings. Surgical management with horizontal shortening of the floppy eyelids remains the mainstay of therapy.

Eyelid, conjunctival, and corneal findings in sleep apnea syndrome

OBJECTIVE

To determine the prevalence of eyelid, conjunctival, and corneal findings in patients with sleep apnea syndrome (SAS).

DESIGN

Case series.

PARTICIPANTS

Seventy-two white patients referred for evaluation of suspected SAS.

INTERVENTION

Complete examination of eyelids, conjunctiva, and cornea, including videokeratography.

MAIN OUTCOME MEASURES

Spearman rank correlations were determined between the respiratory disturbance index (RDI) during night sleep, a value used to diagnose and grade SAS, and tear film break-up time, eyelid distraction distance, presence or absence of ocular irritation symptoms, blepharoptosis, floppy eyelids, lacrimal gland prolapse, keratoconus, and endothelial dystrophy. Each correlation was controlled for age and body mass index.

RESULTS

According to the RDI, 44 (61 %) of the 72 patients had SAS. The RDI correlated positively with the eyelid distraction distance (P = 0.05), presence or absence of floppy eyelids (P = 0.01), and lacrimal gland prolapse (P = 0.01), and correlated negatively with tear film break-up time (P = 0.02). None of our patients with floppy eyelids had corneal abnormalities. One patient with SAS had bilateral keratoconus; another had bilateral Fuch endothelial dystrophy.

CONCLUSIONS

Sleep apnea syndrome was significantly associated with reduced tear film break-up time, floppy eyelids, and lacrimal gland prolapse. However, ocular irritation symptoms and corneal involvement were rare among patients with SAS. These findings do not confirm previous studies that reported a high prevalence of corneal involvement in floppy eyelid syndrome.

A new physical finding in floppy eyelid syndrome

OBJECTIVE

The authors noted that many of their patients with the floppy eyelid syndrome had a unique finding of eyelash ptosis and lashes that curled in many directions. The purpose of this study was to determine how many of these patients had this physical finding.

DESIGN

Case series.

PARTICIPANTS

The authors retrospectively reviewed the charts and photographs of eight consecutive patients with the floppy eyelid syndrome. They also examined four new patients with floppy eyelid syndrome.

INTERVENTION

Surgical tightening of 13 upper lids was performed in 9 patients.

MAIN OUTCOME MEASURES

Relief of symptoms and normalization of eyelash position.

RESULTS

All of the 12 consecutive patients with floppy eyelid syndrome demonstrated eyelash ptosis with loss of eyelash parallelism. All patients treated with surgical shortening of the affected eyelid were asymptomatic at follow-up.

CONCLUSIONS

The authors have identified a new physical finding in the floppy eyelid syndrome: eyelash ptosis with loss of eyelash parallelism. The authors believe that this new physical finding is characteristic of the floppy eyelid syndrome, and will aid in the timely diagnosis and treatment of this sometimes obscure syndrome.

Functional indications for upper and lower eyelid blepharoplasty. American Academy of Ophthalmology

The purpose of the Committee on Ophthalmic Procedures Assessment is to evaluate on a scientific basis new and existing ophthalmic tests, devices, and procedures for their safety, efficacy, clinical effectiveness, and appropriate uses. Evaluations include examination of available literature, epidemiological analyses when appropriate, and compilation of opinions from recognized experts and other interested parties. After appropriate review by all contributors, including legal counsel, assessments are submitted to the Academy's Board of Trustees for consideration as official Academy policy.

The lax eyelid syndrome

The floppy eyelid syndrome (FES) was first described in middle aged, obese men. In later descriptions, age and sex were not specifically mentioned. Associations of FES with various other syndromes have been described. The authors question whether all these cases represent the same, single, syndrome. They suggest that a clinical picture similar to FES may occur in lax upper eyelids of any cause. Four such cases are reported here. The authors therefore coin the more general term 'lax eyelid syndrome'. They suggest using the term 'floppy eyelid syndrome' uniquely for patients with the classic signs and symptoms.

Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin

PURPOSE

Patients with the floppy eyelid syndrome have chronic papillary conjunctivitis with easily everted upper eyelids and a soft, pliant upper tarsus. The purpose of this study is to describe the clinical features and the histopathologic correlate in a group of patients with floppy eyelid syndrome.

METHODS

The authors examined eight patients with floppy eyelid syndrome, four of whom underwent surgical management with horizontal eyelid shortening. Eyelid tissue from these patients was examined using light microscopy, electron microscopy, and immunohistochemistry and compared with controls with unrelated eyelid or orbital disorders.

RESULTS

Clinical findings included obesity or eye rubbing, lash ptosis, and, less commonly, blepharoptosis. Two patients had documented sleep apnea with abnormal sleep electroencephalogram. Light microscopy of the surgical specimens showed chronic conjunctival inflammation, papillary conjunctivitis, and meibomian gland abnormalities, including granuloma formation. Verhoeff's modified elastin stain demonstrated a marked decrease in the amount of elastin fibers in tarsus from patients with floppy eyelid syndrome compared with controls. Immunohistochemical staining for elastin also showed a marked decrease of tarsal elastin in floppy eyelid patients compared with controls. In contrast, immunohistochemical stains showed that the distribution of collagen types I and III was similar between patients with floppy eyelid syndrome and controls. Electron microscopy demonstrated that tarsal collagen was comparable in patients and controls, and that there was a reduced amount of tarsal elastin in floppy eyelid syndrome compared with controls.

CONCLUSIONS

These findings demonstrate that tarsal elastin is decreased in the floppy eyelid syndrome, which may contribute to the laxity of the tarsus in this disorder.

Functional indications for upper and lower eyelid blepharoplasty. American Academy of Ophthalmology

The purpose of the Committee on Ophthalmic Procedures Assessment is to evaluate on a scientific basis new and existing ophthalmic tests, devices, and procedures for their safety, efficacy, clinical effectiveness and appropriate uses. Evaluations include examination of available literature, epidemiological analyses when appropriate, and compilation of opinions from recognized experts and other interested parties. After appropriate review by all contributors, including legal counsel, assessments are submitted to the Academy's Board of Directors for consideration as official Academy policy.

Floppy eyelid syndrome and blepharochalasis

Floppy eyelid syndrome and blepharochalasis may represent a spectrum of one underlying disease. Two patients with floppy eyelid syndrome and one with blepharochalasis shared important clinical similarities. All three patients displayed eyelid laxity associated with papillary conjunctivitis and ocular surface abnormalities. Histopathologic findings were similar in the three cases, characterized by chronic conjunctival inflammation with normal tarsal collagen. In all three patients surgical horizontal eyelid shortening led to improvement in symptoms and findings.