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Surgical Management of Floppy Eyelid Syndrome
Surgical Management of Floppy Eyelid Syndrome Jonathan J. Dutton, M.D. Four patients (five eyes) with the classic findings of floppy eyelid syndrome all had chronic irritative symptoms, with papillary conjunctivitis, and a soft, rubbery, floppy, and easily everted upper eyelid. All affected eyes were treated surgically by a fullthickness eyelid shortening procedure which produced immediate relief of symptoms. Histopathologic study of the resected eyelids showed only an inflammatory infiltrate in the conjunctiva, but failed to identify specific cause- for the lax tarsus. THE FLOPPY EYELID SYNDROME was described by Culbertson and Ostler in 1981. 1 They described 11 obese male patients with laxity of the upper eyelid tarsal plates, chronic papillary conjunctivitis, and nonspecific irritative symptoms not easily controlled with topical medications. Since that time an additionaI 12 patients have been described. 2"; All reported cases were treated with nocturnal eye shields, taping of the eyelids, or topical lubricants. In four patients with the classic findings of floppy eyelid syndrome surgical treatment produced complete resolution of their symptoms.
Csse Reports Case 1 A 62-year-old obese man had a history of chronic conjunctivitis with morning mattering, worse in the left eye, dating back to 1970. At that time he was noted to have papillary hypertrophy of the tarsal conjunctiva of both upper eyelids. He was treated with a variety of topical medications with minimal improvement. In 1971 he developed a marked superficial keratitis poorly responsive to medical management. In 1976 he underwent bilateral cataract extractions and was fitted with contact lenses. He developed corneal neovascularization bilaterally and was unable to continue using these lenses. He com-
Accepted for publication Feb. 18, 1985. From the Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina. Reprint requests to Jonathan J. Dutton, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
plained of a chronic thick mucoid discharge and spontaneous eversion of his eyelids during sleep. Because of some redundant upper eyelid skin, he underwent bilateral blepharoplasties with no improvement in his symptoms. In 1981 he was noted to have lax upper eyelids and was thought to have the floppy eyelid syndrome. He continued to use a variety of topical medications but these failed to relieve the irritation. When he was first seen in the Oculoplastics Clinic in October 1983, his visual acuity was R.E.: 20/25 and L.E.: 20/30. There was marked papillary conjunctivitis, worse on the left side, and a rubbery, floppy upper eyelid tarsus that everted easily. The patient habitually slept on his stomach, preferentially on the left side. In December 1983 he underwent a 7-mm fullthickness pentagonal wedge resection of the lateral portion of the left upper eyelid with primary layered repair. Postoperatively the eyelid was in excellent position and no longer everted spontaneously. The patient's irritative symptoms improved without the further use of topical medications. He has been followed up for one year without recurrence. Histopathologic study disclosed chronic inflammation of the conjunctiva but morphologically normal tarsus. Case 2 This 52-year-old obese man first noted the onset of irritation in his right eye and a chronic discharge in 1974. He was thought to have blepharoconjunctivitis and was treated intermittently with topical antibiotics, corticosteroids, vasoconstrictors, and artificial tears without significant improvement. In June 1982 mild punctate keratitis developed in the right eye with blurring of vision. At my initial examination his visual acuity was R.E.: 20/70 and L.E.: 20/20. There was a marked papillary reaction of the right upper tarsal conjunctiva and a thick, ropy mucoid accumulation beneath the upper eyelid. The upper tarsal plate was soft and lax, and everted easily (Fig. 1, top left). The patient habitually slept on the right side of his face. A conjunctival scraping disclosed metaplastic squamous epithelium. In December 1984 the patient underwent an eyelid shortening procedure with a 10-mm excision of the
©AMERICAN JOURNAL OF OPHTHALMOLOGY 99:557-560, MAy, 1985
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Fig. 1 (Dutton). Case 2. Top left, Preoperative condition showing marked floppiness of eyelid, which is easily everted. Top right, Area of lateral eyelid excised by full-thickness excision. Bottom left, Postoperative appearance with sutures in place.
lateral right upper eyelid followed by primary layered closure (Fig. 1/ top right and bottom left). Postoperatively the eyelid was in good position and no longer spontaneously everted. The patient's irritative symptoms were significantly improved without topical medication. Histopathologic study showed keratinized stratified squamous epithelium replacing the conjunctival epithelium with some infiltration of neutrophils. Goblet cells were absent. The tarsal connective tissue appeared morphologically normal. Case 3 This 50-year-old obese man had a one-year history of pain in both eyes upon awakening in the morning. His eyes were chronically red with a thick mucoid discharge. The patient had to tape his eyelids closed at night to minimize these symptoms. At my initial examination his visual acuity was 20/20 in each eye. A marked papillary conjunctivitis was present on the tarsal conjunctiva of both upper eyelids, and there was a mild blepharitis. The upper eyelids were very lax and the tarsus was easily stretched to the level of the eyebrows. They could be everted easily with little effort (Fig. 2/ left). The upper eyelids overhung the lower eyelid margins when the eyes were closed.
In August 1984 the patient underwent bilateral eyelid shortening procedures with lateral tarsal strip fixation to the periosteum of the lateral orbital rims." Each eyelid was shortened 15 mm (Fig. 2/ right). Postoperatively the eyelids were in excellent position, no longer overhanging the lower eyelid margins. The patient has remained comfortable without irritative symptoms for six months since the operation. Histopathologic study of the excised segment of eyelid showed chronic conjunctival inflammation. The tarsus demonstrated only dense connective tissue without any structural abnormalities. Case 4 A 47-year-old obese man complained of having had burning, irritation, and a thick sticky discharge in his left eye for eight months. More recently, he had noted decreased vision in his left eye. At my initial examination his visual acuity was R.E.: 20/15 and L.E.: 20/40. There was a papillary conjunctivitis on the tarsal conjunctiva of the left upper eyelid and a superficial punctate keratopathy. The left upper eyelid tarsal plate was soft and floppy, and the eyelid was easily everted (Fig. 3). There was also a retinal pigment epithelial detachment without central serous retinopathy; this accounted for his
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Fig. 2 (Dutton). Case 3. Left, Preoperative condition showing upper tarsal plate floppiness and conjunctivitis. Right, Surgical excision of lateral eyelid with partial closure.
decreased VISIOn. The irritative eyelid symptoms improved somewhat with topical corticosteroids. On Dec. 5, 1984, the patient underwent an eyelid shortening procedure with a lO-mm full-thickness pentagonal excision of the lateral left upper eyelid and primary layered closure. Postoperatively the eyelid was no longer lax and did not evert easily, and the patient's irritative symptoms resolved without further use of topical medications.
Histopathologic study demonstrated a chronic inflammatory reaction of the conjunctiva but failed to show any abnormality of the tarsus.
Discussion All 11 of Culbertson and Ostler's' patients with chronic papillary conjunctivitis of unknown origin
Fig. 3 (Dutton). Case 4. Top left, Preoperative appearance of left upper eyelid. Top right, Floppy, easily stretched left upper eyelid showing loss of tarsal firmness. Bottom left, Postoperative appearance of shortened left upper eyelid.
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were obese men with chronic, nonspecific irritation, foreign body sensation, and mucoid discharge. Many of these patients slept on their faces, preferentially on the side of greater eyelid involvement. Many also reported spontaneous eyelid eversion during sleep. Clinically, all demonstrated a rubbery, floppy upper eyelid with loss of tarsal firmness. Conjunctival scrapings showed papillary hypertrophy with keratinization and thickening. Tarsal biopsy specimens from three patients demonstrated normal structure and thickness of the tarsal plate with a mild nonspecific inflammatory infiltrate. Culbertson and Ostler suggested a structural abnormality of the tarsus as the primary cause of the disease, with conjunctivitis resulting from chronic eversion during sleep. All 11 patients were successfully treated with an eye shield taped over the eyelids at night to prevent nocturnal eyelid eversion. Culbertson and Ostler also mentioned a 12th patient, an obese woman, who was also thought to have the syndrome, but she was not included in the series. In 1983 Parunovic'' mentioned another seven patients with floppy eyelid syndrome and described three of them. As in the original description, all were obese, middle-aged men with floppy eyelids and papillary conjunctivitis. In one of these patients, symptoms spontaneously resolved upon loss of weight. Several others obtained relief by taping their eyelids closed at night. Schwartz, Gelender, and Forster' described an additional seven patients with the classic signs of this syndrome, again confirming the findings previously described. They treated their patients with eye shields or topical lubricants for control of the irritative symptoms. Paciuc and Mier'' described the syndrome in an obese woman. Gerner and Hughes" treated a patient with floppy eyelid syndrome and hyperglycinemia by an eyelid shortening procedure with relief of symptoms. My patients had all the characteristic findings of the floppy eyelid syndrome. All had soft, stretchable, and floppy upper eyelids, papillary conjunctivitis, and spontaneously everting eyelids during sleep. All preferred sleeping on their stomachs, on the side of greater eyelid involvement. In all four of these patients medical management with topical corticosteroids and lubricants was only marginally successful. To date 27 patients with this syndrome have been formally described. An additional five patients have been mentioned in the literature, one of whom was a woman, but no other data are available for them. The 26 men and one woman who have been described ranged in age from 31 to 80 years (mean, 51 years). In 16 cases the condition was bilateral. Twenty-one of these patients were obese; in six cases weight was not specified. Twenty-four patients had chronic papillary conjunctivitis, and in all cases the tarsal plates
were soft, rubbery, and easily stretched and everted. Most patients reported that their symptoms were worse in the morning upon awakening. The mean duration of symptoms before diagnosis of the condition was 5.3 years (range, eight months to 14 years). The major symptoms included redness, eyelid swelling, a thick mucoid discharge, and foreign body sensation. Less common clinical findings included superficial punctate keratopathy and superior limbal corneal pannus formation. A characteristic of this syndrome is the inability to control symptoms with topical medications and lubricants. Most patients had to use shields or taping of the eyelids during sleep. In my four patients (five eyes) I attempted to correct the stretched and floppy eyelid with an eyelid shortening procedure. A full-thickness resection of the lateral one third to one half of the eyelid was performed with primary layered closure. In all cases the patient experienced immediate relief of symptoms, and the eyelid no longer everted spontaneously during sleep. I believe that the chronic symptoms of the floppy eyelid syndrome can be easily managed surgically, eliminating the need for nightly taping or the use of shields. The cause of the floppy eyelid syndrome remains obscure. Histologic examination of the tarsus failed to demonstrate any conclusive structural abnormalities, despite the clear clinical changes in tarsal stability found in all such patients. A mild chronic inflammatory infiltrate has been reported in some cases, but it is uncertain whether this was a primary cause or a secondary effect. My findings agreed with those of previous investigators that the syndrome appears to result from a loss of tarsal integrity, and is perhaps related to sleeping habitually on the eyelid in patients with excessive weight. The chronic conjunctivitis and consequent irritative symptoms appear to be secondary changes related to spontaneous eyelid eversion during sleep.
References 1. Culbertson, W. W., and Ostler, H. B.: The floppy eyelid syndrome. Am. J. Ophthalmol. 92:568, 1981. 2. Paciuc, M., and Mier, M. E.: A woman with the floppy eyelid syndrome, letter. Am. J. Ophthalmol. 93:255, 1982. 3. Parunovic, A.: Floppy eyelid syndrome. Br. J. Ophthalmol. 67:264, 1983. 4. Schwartz, L. K., Gelender, H., and Forster, R. K.: Chronic conjunctivitis associated with "floppy eyelids." Arch. Ophthalmol. 101:1884, 1983. 5. Gerner, E. W., and Hughes, S. M.: Floppy eyelid with hyperglycinemia. Am. J. Ophthalmol. 98:614, 1984. 6. Anderson, R. L., and Gordy, D. D.: The tarsal strip procedure. Arch. Ophthalmol. 97:2192, 1979.
Csse Reports Case 1 A 62-year-old obese man had a history of chronic conjunctivitis with morning mattering, worse in the left eye, dating back to 1970. At that time he was noted to have papillary hypertrophy of the tarsal conjunctiva of both upper eyelids. He was treated with a variety of topical medications with minimal improvement. In 1971 he developed a marked superficial keratitis poorly responsive to medical management. In 1976 he underwent bilateral cataract extractions and was fitted with contact lenses. He developed corneal neovascularization bilaterally and was unable to continue using these lenses. He com-
Accepted for publication Feb. 18, 1985. From the Department of Ophthalmology, Duke University Eye Center, Durham, North Carolina. Reprint requests to Jonathan J. Dutton, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710.
plained of a chronic thick mucoid discharge and spontaneous eversion of his eyelids during sleep. Because of some redundant upper eyelid skin, he underwent bilateral blepharoplasties with no improvement in his symptoms. In 1981 he was noted to have lax upper eyelids and was thought to have the floppy eyelid syndrome. He continued to use a variety of topical medications but these failed to relieve the irritation. When he was first seen in the Oculoplastics Clinic in October 1983, his visual acuity was R.E.: 20/25 and L.E.: 20/30. There was marked papillary conjunctivitis, worse on the left side, and a rubbery, floppy upper eyelid tarsus that everted easily. The patient habitually slept on his stomach, preferentially on the left side. In December 1983 he underwent a 7-mm fullthickness pentagonal wedge resection of the lateral portion of the left upper eyelid with primary layered repair. Postoperatively the eyelid was in excellent position and no longer everted spontaneously. The patient's irritative symptoms improved without the further use of topical medications. He has been followed up for one year without recurrence. Histopathologic study disclosed chronic inflammation of the conjunctiva but morphologically normal tarsus. Case 2 This 52-year-old obese man first noted the onset of irritation in his right eye and a chronic discharge in 1974. He was thought to have blepharoconjunctivitis and was treated intermittently with topical antibiotics, corticosteroids, vasoconstrictors, and artificial tears without significant improvement. In June 1982 mild punctate keratitis developed in the right eye with blurring of vision. At my initial examination his visual acuity was R.E.: 20/70 and L.E.: 20/20. There was a marked papillary reaction of the right upper tarsal conjunctiva and a thick, ropy mucoid accumulation beneath the upper eyelid. The upper tarsal plate was soft and lax, and everted easily (Fig. 1, top left). The patient habitually slept on the right side of his face. A conjunctival scraping disclosed metaplastic squamous epithelium. In December 1984 the patient underwent an eyelid shortening procedure with a 10-mm excision of the
©AMERICAN JOURNAL OF OPHTHALMOLOGY 99:557-560, MAy, 1985
557
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AMERICAN JOURNAL OF OPHTHALMOLOGY
May/ 1985
Fig. 1 (Dutton). Case 2. Top left, Preoperative condition showing marked floppiness of eyelid, which is easily everted. Top right, Area of lateral eyelid excised by full-thickness excision. Bottom left, Postoperative appearance with sutures in place.
lateral right upper eyelid followed by primary layered closure (Fig. 1/ top right and bottom left). Postoperatively the eyelid was in good position and no longer spontaneously everted. The patient's irritative symptoms were significantly improved without topical medication. Histopathologic study showed keratinized stratified squamous epithelium replacing the conjunctival epithelium with some infiltration of neutrophils. Goblet cells were absent. The tarsal connective tissue appeared morphologically normal. Case 3 This 50-year-old obese man had a one-year history of pain in both eyes upon awakening in the morning. His eyes were chronically red with a thick mucoid discharge. The patient had to tape his eyelids closed at night to minimize these symptoms. At my initial examination his visual acuity was 20/20 in each eye. A marked papillary conjunctivitis was present on the tarsal conjunctiva of both upper eyelids, and there was a mild blepharitis. The upper eyelids were very lax and the tarsus was easily stretched to the level of the eyebrows. They could be everted easily with little effort (Fig. 2/ left). The upper eyelids overhung the lower eyelid margins when the eyes were closed.
In August 1984 the patient underwent bilateral eyelid shortening procedures with lateral tarsal strip fixation to the periosteum of the lateral orbital rims." Each eyelid was shortened 15 mm (Fig. 2/ right). Postoperatively the eyelids were in excellent position, no longer overhanging the lower eyelid margins. The patient has remained comfortable without irritative symptoms for six months since the operation. Histopathologic study of the excised segment of eyelid showed chronic conjunctival inflammation. The tarsus demonstrated only dense connective tissue without any structural abnormalities. Case 4 A 47-year-old obese man complained of having had burning, irritation, and a thick sticky discharge in his left eye for eight months. More recently, he had noted decreased vision in his left eye. At my initial examination his visual acuity was R.E.: 20/15 and L.E.: 20/40. There was a papillary conjunctivitis on the tarsal conjunctiva of the left upper eyelid and a superficial punctate keratopathy. The left upper eyelid tarsal plate was soft and floppy, and the eyelid was easily everted (Fig. 3). There was also a retinal pigment epithelial detachment without central serous retinopathy; this accounted for his
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Fig. 2 (Dutton). Case 3. Left, Preoperative condition showing upper tarsal plate floppiness and conjunctivitis. Right, Surgical excision of lateral eyelid with partial closure.
decreased VISIOn. The irritative eyelid symptoms improved somewhat with topical corticosteroids. On Dec. 5, 1984, the patient underwent an eyelid shortening procedure with a lO-mm full-thickness pentagonal excision of the lateral left upper eyelid and primary layered closure. Postoperatively the eyelid was no longer lax and did not evert easily, and the patient's irritative symptoms resolved without further use of topical medications.
Histopathologic study demonstrated a chronic inflammatory reaction of the conjunctiva but failed to show any abnormality of the tarsus.
Discussion All 11 of Culbertson and Ostler's' patients with chronic papillary conjunctivitis of unknown origin
Fig. 3 (Dutton). Case 4. Top left, Preoperative appearance of left upper eyelid. Top right, Floppy, easily stretched left upper eyelid showing loss of tarsal firmness. Bottom left, Postoperative appearance of shortened left upper eyelid.
560
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AMERICAN JOURNAL OF OPHTHALMOLOGY
were obese men with chronic, nonspecific irritation, foreign body sensation, and mucoid discharge. Many of these patients slept on their faces, preferentially on the side of greater eyelid involvement. Many also reported spontaneous eyelid eversion during sleep. Clinically, all demonstrated a rubbery, floppy upper eyelid with loss of tarsal firmness. Conjunctival scrapings showed papillary hypertrophy with keratinization and thickening. Tarsal biopsy specimens from three patients demonstrated normal structure and thickness of the tarsal plate with a mild nonspecific inflammatory infiltrate. Culbertson and Ostler suggested a structural abnormality of the tarsus as the primary cause of the disease, with conjunctivitis resulting from chronic eversion during sleep. All 11 patients were successfully treated with an eye shield taped over the eyelids at night to prevent nocturnal eyelid eversion. Culbertson and Ostler also mentioned a 12th patient, an obese woman, who was also thought to have the syndrome, but she was not included in the series. In 1983 Parunovic'' mentioned another seven patients with floppy eyelid syndrome and described three of them. As in the original description, all were obese, middle-aged men with floppy eyelids and papillary conjunctivitis. In one of these patients, symptoms spontaneously resolved upon loss of weight. Several others obtained relief by taping their eyelids closed at night. Schwartz, Gelender, and Forster' described an additional seven patients with the classic signs of this syndrome, again confirming the findings previously described. They treated their patients with eye shields or topical lubricants for control of the irritative symptoms. Paciuc and Mier'' described the syndrome in an obese woman. Gerner and Hughes" treated a patient with floppy eyelid syndrome and hyperglycinemia by an eyelid shortening procedure with relief of symptoms. My patients had all the characteristic findings of the floppy eyelid syndrome. All had soft, stretchable, and floppy upper eyelids, papillary conjunctivitis, and spontaneously everting eyelids during sleep. All preferred sleeping on their stomachs, on the side of greater eyelid involvement. In all four of these patients medical management with topical corticosteroids and lubricants was only marginally successful. To date 27 patients with this syndrome have been formally described. An additional five patients have been mentioned in the literature, one of whom was a woman, but no other data are available for them. The 26 men and one woman who have been described ranged in age from 31 to 80 years (mean, 51 years). In 16 cases the condition was bilateral. Twenty-one of these patients were obese; in six cases weight was not specified. Twenty-four patients had chronic papillary conjunctivitis, and in all cases the tarsal plates
were soft, rubbery, and easily stretched and everted. Most patients reported that their symptoms were worse in the morning upon awakening. The mean duration of symptoms before diagnosis of the condition was 5.3 years (range, eight months to 14 years). The major symptoms included redness, eyelid swelling, a thick mucoid discharge, and foreign body sensation. Less common clinical findings included superficial punctate keratopathy and superior limbal corneal pannus formation. A characteristic of this syndrome is the inability to control symptoms with topical medications and lubricants. Most patients had to use shields or taping of the eyelids during sleep. In my four patients (five eyes) I attempted to correct the stretched and floppy eyelid with an eyelid shortening procedure. A full-thickness resection of the lateral one third to one half of the eyelid was performed with primary layered closure. In all cases the patient experienced immediate relief of symptoms, and the eyelid no longer everted spontaneously during sleep. I believe that the chronic symptoms of the floppy eyelid syndrome can be easily managed surgically, eliminating the need for nightly taping or the use of shields. The cause of the floppy eyelid syndrome remains obscure. Histologic examination of the tarsus failed to demonstrate any conclusive structural abnormalities, despite the clear clinical changes in tarsal stability found in all such patients. A mild chronic inflammatory infiltrate has been reported in some cases, but it is uncertain whether this was a primary cause or a secondary effect. My findings agreed with those of previous investigators that the syndrome appears to result from a loss of tarsal integrity, and is perhaps related to sleeping habitually on the eyelid in patients with excessive weight. The chronic conjunctivitis and consequent irritative symptoms appear to be secondary changes related to spontaneous eyelid eversion during sleep.
References 1. Culbertson, W. W., and Ostler, H. B.: The floppy eyelid syndrome. Am. J. Ophthalmol. 92:568, 1981. 2. Paciuc, M., and Mier, M. E.: A woman with the floppy eyelid syndrome, letter. Am. J. Ophthalmol. 93:255, 1982. 3. Parunovic, A.: Floppy eyelid syndrome. Br. J. Ophthalmol. 67:264, 1983. 4. Schwartz, L. K., Gelender, H., and Forster, R. K.: Chronic conjunctivitis associated with "floppy eyelids." Arch. Ophthalmol. 101:1884, 1983. 5. Gerner, E. W., and Hughes, S. M.: Floppy eyelid with hyperglycinemia. Am. J. Ophthalmol. 98:614, 1984. 6. Anderson, R. L., and Gordy, D. D.: The tarsal strip procedure. Arch. Ophthalmol. 97:2192, 1979.