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

The Overlooked Floppy Eyelid Syndrome: From Diagnosis to Medical and Surgical Management

Floppy Eyelid Syndrome (FES) is an underdiagnosed ocular condition characterized by the abnormal laxity of the upper eyelids, often leading to chronic eye irritation and redness. This review provides an in-depth examination of FES, covering its pathophysiology, clinical presentation, and diagnostic and therapeutic approaches. We discuss the potential etiological factors, including genetic predispositions and associations with ocular and systemic conditions such as obesity, obstructive sleep apnea, keratoconus, and glaucoma. Diagnostic strategies are outlined, emphasizing the importance of thorough clinical examinations and specific tests for an efficacious grading and assessment of FES. Management of FES ranges from conservative medical treatments to surgical interventions for more severe cases and should be driven by a comprehensive and multidisciplinary approach. Herein, we illustrate the practical aspects of diagnosing and managing this condition. This comprehensive review aims to enhance the recognition and treatment of FES, ultimately improving the quality of life for affected patients.

Obesity, body fat distribution and eye diseases

BACKGROUND

The prevalence of obesity, a chronic disease, is increasing, and obesity is now considered a global epidemic. Eye diseases are also increasing worldwide and have serious repercussions on quality of life as well as increasingly high costs for the community. The relationships between obesity and ocular pathologies are not yet well clarified and are not pathologically homogeneous: they seem to be somehow linked to excess body fat, especially to the distribution of adipose tissue and its ectopic deposits.

PURPOSE

Our objective was to examine the associations between obesity and anthropometric indices, including body mass index (BMI), waist circumference (WC), and the waist/hip ratio (WHR), and the risk of most widespread eye diseases, with particular attention given to the most significant metabolic mechanisms.

METHODS

This article provides a narrative overview of the effect of obesity and anthropometric measurements of body fat on prevalent eye diseases. We used the MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library databases from 1984 to 2024. In addition, we hand-searched references from the retrieved articles and explored a number of related websites. A total of 153 publications were considered.

RESULTS

There is significant evidence that obesity is associated with several eye diseases. Waist circumference (WC) and the waist/hip ratio (WHR) have been observed to have stronger positive associations with eye diseases than BMI.

CONCLUSIONS

Obesity must be considered a significant risk factor for eye diseases; hence, a multidisciplinary and multidimensional approach to treating obesity, which also affects ocular health, is important. In the prevention and treatment of eye diseases related to obesity, lifestyle factors, especially diet and physical activity, as well as weight changes, both weight loss and weight gain, should not be overlooked.

LEVEL OF EVIDENCE

Level V narrative review.

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.

Ocular manifestations of obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

The association of obstructive sleep apnea (OSA) with development of eye diseases is unclear. This current systematic review and meta-analysis attempts to summarize and analyze associations between OSA and ocular disorders in the literature.

METHODS

PubMed, EMBASE, Google Scholar, Web Of Science, and Scopus databases were searched from 1901 to July 2022 in accordance with the Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA). Our primary outcome assessed the association between OSA and the odds of developing floppy eyelid syndrome (FES), glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), retinal vein occlusion (RVO), keratoconus (KC), idiopathic intracranial hypertension (IIH), age-related macular degeneration (AMD), and central serous chorioretinopathy (CSR) through odds ratio calculated at the 95% confidence interval.

RESULTS

Forty-nine studies were included for systematic review and meta-analysis. The pooled OR estimate was highest for NAION [3.98 (95% CI 2.38, 6.66)], followed by FES [3.68 (95% CI 2.18, 6.20)], RVO [2.71(95% CI 1.83, 4.00)], CSR [2.28 (95% CI 0.65, 7.97)], KC [1.87 (95% CI 1.16, 2.99)], glaucoma [1.49 (95% CI 1.16, 1.91)], IIH [1.29 (95% CI 0.33, 5.01)], and AMD [0.92 [95% CI 0.24, 3.58] All observed associations were significant (p < 0.001) aside from IIH and AMD.

CONCLUSION

OSA is significantly associated with NAION, FES, RVO, CSR, KC, and glaucoma. Clinicians should be informed of these associations so early recognition, diagnosis, and treatment of eye disorders can be addressed in at-risk groups, and early referral to ophthalmic services is made to prevent vision disturbances. Similarly, ophthalmologists seeing patients with any of these conditions should consider screening and referring patients for assessment of possible OSA.

Tape-splint tarsorrhaphy technique to manage exposure keratopathy in a patient refusing surgical intervention

This case report describes the benefits of a unique tape-splinting technique to serve as a nonsurgical tarsorrhaphy in the management of exposure keratopathy in a patient who refuses surgical intervention.

Comparison of ocular surface assessment outcomes between healthy controls and patients with obstructive sleep apnea-hypopnea syndrome: a meta-analysis of the literature

Objective: This meta-analysis aims to determine whether ocular surface alterations are associated with disease severity in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Methods: The protocol for this systematic review and meta-analysis was registered in PROSPERO. We conducted the search in six electronic databases (China National Knowledge Infrastructure, EMBASE, Cochrane Library, Web of Science, Wanfang, and PubMed) from since the construction of the databases to 30 December 2022. The standard mean difference (SMD) and correlation coefficients are reported as measures of the effect size in the presence of retrieved data. In addition, the random effects model or fixed effects model was used in a combined analysis. Stata 11.0 and R 3.6.1 were used for statistical analyses of the data. Results: A total of 15 studies satisfied the inclusion criteria for this study. The prevalence of floppy eyelid syndrome (FES) and dry eye syndrome in patients with obstructive sleep apnea-hypopnea syndrome was 40 and 48%, respectively. In addition, the Schirmer 1 value and tear break-up time (TBUT) were remarkably reduced in patients with OSAHS when compared to that of the controls. The ocular surface disease index (OSDI) scores, Oxford corneal staining scores, and the rates of loss in the meibomian glands were elevated in patients with obstructive sleep apnea-hypopnea syndrome when compared to that of the controls, especially those with severe disease. Moreover, the Schirmer 1 value and tear break-up time exhibited a negative correlation with the apnea-hypopnea index (AHI), and the OSDI showed a positive association with the apnea-hypopnea index. Conclusion: Patients with OSAHS had a greater prevalence of FES than the healthy controls. They also showed lower Schirmer 1 value and tear break-up time but had a higher OSDI, Oxford corneal staining scores, and rates of loss in the meibomian glands than the healthy controls. Clinical Trial Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=392527).