Off the Cuff: Funny Sounding Name, Serious Implications

It is always interesting when associations emerge between specific clinical findings and a seemingly unrelated condition. One particular association that seems to pop up consistently involves the descriptively named floppy eyelid syndrome (FES) and sleep apnea. Many are likely familiar with this association, but I am often astounded by how common this finding is in daily practice. However, I should not be too surprised considering that it is estimated that 14-49% of middle-age men in the US and Europe have clinically significant sleep apnea.¹ This is why any time I pull down on the lower lid or lift the upper during the course of an exam, and the lids evert with only the slightest effort or even double over on themselves, my mind immediately jumps to sleep apnea. This excessive lid laxity is the ocular hallmark of the disease, but it often goes undiagnosed. And as Dr. Steinhäuser has noted and written about previously, hemorrhages in the retinal periphery also appear to be a sign of sleep apnea, so it is not as though the condition is failing to make its presence known. What is perhaps most surprising about how often sleep apnea-associated FES flies under the radar is the fact that, despite its somewhat humorous sounding name, it is not an inconsequential disease.

From an ocular surface standpoint, it can cause significant disruption including recurrent corneal erosions, chronic papillary conjunctivitis with copious mucus production due to excessive mechanical friction as the loose lids rub against the ocular surface, dry eye caused by nocturnal exposure, and abrasions associated with spontaneous lid eversion that may occur during sleep. Even patients who are being treated with a CPAP or BiPAP are not out of the woods, as even the best of mask seals are often not perfect, and it is not unusual for these patients to have issues with nocturnal dryness due to the evaporative stress of air blowing over the ocular surface the entire night. However, even more concerning is the fact that sleep apnea has been associated with non-arteritic anterior ischemic optic neuropathy, as the repeated apneic episodes can lead to hypoperfusion of the optic nerve during sleep, as well as CRVO and BRVO. Yet even more dire are the potential systemic health implications, as untreated sleep apnea can increase the risk of heart attack, stroke, cardiac arrythmia, and even congestive heart failure.

So, every time I observe FES, I ask the patient if they have any issues sleeping—specifically if they often wake up feeling tired even though they got a full night of sleep, or if they know if they snore. Typically, I get one of two responses—either something along the lines of “Oh yeah, I have sleep apnea and I use a CPAP” or “I do feel tired all the time and my wife says my snoring shakes the house.” What is particularly interesting is that patients time and time again, for some reason, do not report having sleep apnea when giving their initial health history. They will report having high blood pressure or diabetes, but they rarely ever mention sleep apnea. This is a strange phenomenon that Dr. Steinhäuser has noticed as well. In cases where patients have all the symptoms of sleep apnea but have not been diagnosed, I always educate them on the risks associated with untreated sleep apnea and advise them to undergo a sleep study.

Also, it is worth noting it is not just the classic overweight, barrel-chested middle-age man who has sleep apnea, we also find it in thin, often elderly, women with low blood pressure, due to risks associated with hypotension. So, whenever you encounter an excessively floppy eyelid, ask the patient about the symptoms of sleep apnea, and you may be surprised by how many have the condition but did not mention it, or how many have it but have never been diagnosed. By noticing a floppy eyelid, you could end up ultimately saving someone’s vision, or even their life.

1. Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis. 2015;7(5):920-9.

Cory J. Lappin, OD, MS, FAAO

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Write to Dr. Shannon L. Steinhäuser, OD, MS, FAAO at ssteinhauser@gmail.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.