Floppy Eyelid Syndrome

Educational Objectives

The goal of this program is to improve the management of floppy eyelid syndrome. After hearing and assimilating this program, the clinician will be better able to:

1. Identify patients likely to have obstructive sleep apnea by the presence of floppy eyelid syndrome.

Summary

Background: floppy eyelid syndrome (FES) was first described in 1981 by Culbertson and Ostler in 11 overweight men with ocular discomfort and discharge, readily everted upper eyelids, papillary conjunctivitis, and keratopathy; the findings were associated with sleeping face-down; the incidence of FES is increasing

Clinical features: in FES, the loose upper eyelid everts during sleep; conjunctivitis results from mechanical trauma where the everted eyelid is in contact with the bedding; many of these cases are more accurately termed lax eyelid syndrome (LES); in FES and LES, placing a thumb on the patient’s eyebrow and pulling up causes the eyelid to evert; associated findings include eyelash ptosis, blepharoptosis, and ectropion; patients have a marked loss of elastin and increased activity of matrix metalloproteinase in the tear film and soft tissues

Obstructive sleep apnea (OSA): present in ≈95% of patients with FES; one theory states that FES is a mechanical problem related to face-down sleeping; in addition, OSA causes intermittent occlusion, ischemia, reperfusion, and low oxygen saturation ( may play a role in the mechanical irritation); the incidence is increasing as the rate of obesity increases; however, ≤20% of patients with OSA are thin and appear fit; these patients may have abnormalities of the upper airway; in patients with OSA, 2% to 40% have lax eyelids; in all patients with FES, polysomnography or home respiratory polygraphy should be performed to diagnose OSA; OSA must be addressed before surgical correction of the eyelids; otherwise, the treatment is likely to fail as the mechanical trauma continues; although most patients with OSA are men, the condition also may be present in women; ocular symptoms often are resolved after OSA is treated; nocturnal eye shields or sleep masks provide a temporary solution

Eyelid surgery: if symptoms persist after OSA is treated, consider surgical tightening of the eyelid by a wedge excision of the elongated eyelid or a tarsal strip procedure; after a central wedge excision, the lax lateral canthal tendon is a pivot point that may allow the eyelid to evert; after a tarsal strip procedure, the eyelid cannot evert easily; in some cases, ptosis resolves after the eyelid is tightened; suspect OSA in patients with wound dehiscence after eyelid surgery or those with recurrence after multiple surgeries for ptosis

Obstructive sleep apnea (OSA)(continued): most cases are associated with obesity; therefore, ≈85% of cases are resolved after bariatric surgery; when patients sleep on their backs, the soft tissues collapse and close off the oral pharynx; sleeping face-down opens up the airway

Associated risks: patients with OSA are 5 times more likely to develop nonarteritic ischemic optic neuropathy and 10 times more likely to develop glaucoma; of patients with normal-tension glaucoma, ≤40% have OSA; patients with mild or severe OSA have a reduced life expectancy

Treatment: the use of bilevel positive airway pressure or continuous positive airway pressure (CPAP) machines allows patients to sleep on their backs; surgical procedures to open the upper airway may be performed; hypoglossal nerve stimulation causes the tongue to move forward during sleep and creates more space in the back of the throat; only 30% to 50% of patients tolerate long-term use of CPAP machines; the goal of treatment is to allow patients to sleep on their backs

Readings

Eastwood PR et al. Bilateral hypoglossal nerve stimulation for treatment of adult obstructive sleep apnoea. Eur Respir J. 2020 Jan;55(1):1901320; Huon LK et al. The association between ophthalmologic diseases and obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath. 2016 Dec;20(4):1145-1154; McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthalmic Plast Reconstr Surg. 1997 Jun;13(2):98-114; Muniesa M et al. The relationship between floppy eyelid syndrome and obstructive sleep apnea. Br J Ophthalmol. 2013;97:1387-1390.

Disclosures

Dr. Kersten reported nothing to disclose. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Kersten spoke at the Ophthalmology Update 2019, sponsored by the University of California, San Francisco, School of Medicine and held December 6, 2019, in San Francisco, CA. For information about upcoming CME conferences from this sponsor, please visit meded.ucsf.edu. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP590802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.