Vol. 2, #18   •   Friday, August 6, 2021


Review's Chief Clinical Editor
Paul M. Karpecki, OD, FAAO

Provides you with cutting-edge clinical strategies for optimal management of ocular surface disease and beyond.


Floppy Eyelid Syndrome: A Condition You Don’t Want to Miss

Certain dry eye disease presentations can be caused by other comorbidities. Although therapeutic agents such as EYSUVIS will treat the dry eye flares associated with them, the condition won’t resolve until the cause is taken care of. One of these is floppy eyelid syndrome (FES).

FES is a relatively rare condition that often masquerades as dry eye disease. Patients may exhibit chronic superficial punctate keratopathy (SPK) and blepharitis. The lack of tight eyelid closure in patients with FES yields chronic corneal and conjunctival inflammation. This persistent irritation often leads to edema, chemosis, staining, and even epithelial abrasions.1 Everting the upper eyelid reveals an extremely elastic eyelid, and patients may even complain of spontaneous lid eversion.2

Because there is a high association with sleep apnea, it is thought that FES patients may have a genetic or developmental problem that reduces the inherent structural rigidity of collagen or elastin tissues, including the eyelid, epiglottis, or pharynx.3,4 Like the upper tarsal plate, the pharynx may lack the necessary structural integrity for proper functioning.5,6

Research has also found a high concentration of matrix metalloproteinase enzymes located on the ocular surface and eyelids of FES patients, which could damage the elastic fibers of the eyelid.7

Finally, patients with FES are more likely to develop keratoconus secondary to a potential structural integrity defect or repetitive nocturnal eye rubbing.8

FES frequently is underdiagnosed or misdiagnosed by eye care providers because patients often present with concurrent SPK and advanced MGD. So, you must carefully evaluate the individual for more unique signs and symptoms of FES to help confirm the diagnosis. For example, be sure to look for a stringy mucous discharge or evidence of severe ocular itch. FES patients also may report a history of corneal abrasions in the complete absence of traumatic insult.

Although the SPK and any concurrent dry eye disease can be treated with EYSUVIS, eyelid tightening surgery often is the only effective treatment option.9 Don’t forget to refer the associated systemic disease components, including sleep apnea, to a sleep specialist or pulmonologist.10 It is also important to be aware of serious ocular findings that are more common in patients with both FES and OSA, including glaucoma and non-arteritic anterior ischemic optic neuropathy.11

KEY TAKEAWAY: A rare condition, FES is often overlooked or misdiagnosed. Flareups with this condition are common, and although they can be managed with EYSUVIS, patients won’t fully respond unless the FES itself is diagnosed and addressed.


1. Moscato EE, Jian-Amadi A. Floppy eyelid syndrome. Compr Ophthalmol Update. 2007 Mar-Apr;8(2):59-65.
2. Kestelyn P, van Liefferinge T, Goes F, et al. A rare case of chronic papillary conjunctivitis diagnosed after several years of evolution. Clinical and pathological findings. Bull Soc Belge Ophtalmol. 1993;248:61-6.
3. Karger RA, White WA, Park WC, et al. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Ophthalmology. 2006;113(9):1669-74.
4. Lee WJ, Kim JC, Shyn KH. Clinical evaluation of corneal diseases associated with floppy eyelid syndrome. Korean J Ophthalmol. 1996 Dec;10(2):116-21.
5. Netland PA, Sugrue SP, Albert DM, et al. Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology. 1994 Oct;10(1)1:174-81.
6. Ezra DG, Beaconsfield M, Collin R. Floppy eyelid syndrome: stretching the limits. Surv Ophthalmol. 2010;55(1):35-46.
7. Schlötzer-Schrehardt U, Stojkovic M, Hofmann-Rummelt C, et al. The pathogenesis of floppy eyelid syndrome: involvement of matrix metalloproteinases in elastic fiber degradation. Ophthalmology. 2005 Apr;112(4):694-704.
8. Ezra DG, Beaconsfield M, Sira M et al. Long-term outcomes of surgical approaches to the treatment of floppy eyelid syndrome. Ophthalmology. 2010 Apr;117(4):839-46.
9. Leibovitch I, Selva D. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Med. 2006 Mar;7(2):117-22.
10. McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea. Clin Experiment Ophthalmol. 2000;28(2):125-6.
11. Abdal H, Pizzimenti JJ, Purvis CC. The eye in sleep apnea syndrome. Sleep Med. 2006 Mar;7(2):107-15.

Supported by an independent medical grant from Kala Pharmaceuticals

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