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Floppy Eyelid Syndrome

Last updated Sept. 14, 2018

Approved by: Krish Tangella MD, MBA, FCAP

Floppy Eyelid Syndrome (FES) is a condition in which the upper eyelid loses its elasticity, thus becoming loose, or “floppy” as opposed to maintaining a tight attachment to the tarsal plate (connective tissue).

What are the other Names for this Condition? (Also known as/Synonyms)

  • FES (Floppy Eyelid Syndrome)

What is Floppy Eyelid Syndrome? (Definition/Background Information)

  • Floppy Eyelid Syndrome (FES) is a condition in which the upper eyelid loses its elasticity, thus becoming loose, or “floppy” as opposed to maintaining a tight attachment to the tarsal plate (connective tissue). The loose upper eyelids become easy to evert (make it inside out)
  • The cause of loosening of eyelids is the reduction in elastin (a protein in connective tissue that helps maintain the shape of eyes). This reportedly occurs in ‘facedown sleepers’, as well as in those with a chronic habit of eye-rubbing. A strong association is noted between obstructive sleep apnea and FES, although the former (apnea) does not directly result in the latter (FES)
  • The age of onset of this disorder is typically during adulthood. The risk factors for developing Floppy Eyelid Syndrome include habit of sleeping facedown, obstructive sleep apnea, and certain medical conditions, such as diabetes and hyperthyroidism
  • Eyelids that are easily everted, redness in the eyes after waking up, and an inflammation of the cornea and/or the tissue underneath the upper eyelids are some typical symptoms of Floppy Eyelid Syndrome. Additionally, if the condition is associated with obstructive sleep apnea, snoring and daytime sleeping may be additionally noted
  • Floppy Eyelid Syndrome is diagnosed through an examination of the eyes and eyelids by a healthcare professional, in conjunction with assessment of the symptoms and the affected individual’s medical history
  • Some complications of this condition include the development of a cone-shaped cornea (due to chronic eye rubbing), dry eyes, chronic inflammation of the cornea and upper eyelids
  • Floppy Eyelid Syndrome may be treated by keeping the eye moist with lubricating ointment, taping the eyes such that the eyes do not dry out, and most importantly, managing the underlying medical condition causing FES. Surgical tightening of the eyelids may also be recommended in some cases
  • Maintenance of a good body mass index, management of conditions such as obstructive sleep apnea, avoiding eye rubbing and sleeping facedown, are some methods for the prevention of Floppy Eyelid Syndrome
  • If the disorder as well as the underlying medical condition are diagnosed and treated in a timely manner, the prognosis of the condition is usually favorable. However, loss of elastin in the eyelids, and consequently their elasticity, can lead to a poorer outcome

Who gets Floppy Eyelid Syndrome? (Age and Sex Distribution)

  • Floppy Eyelid Syndrome is an uncommon medical condition
  • FES is reported in the age range of 25-80 years. However, middle-aged individuals (40-50 years) report this condition more commonly than other age groups
  • Although both genders may be affected, males are marginally more vulnerable to the condition than females
  • There is no racial or ethnic bias reported in the occurrence of this disorder

What are the Risk Factors for Floppy Eyelid Syndrome? (Predisposing Factors)

The following are some risk factors associated with Floppy Eyelid Syndrome:

  • Obesity
  • Obstructive sleep apnea: There exists a strong positive association of this eye disorder with obstructive sleep apnea
  • Chronic eye rubbing
  • Diabetes mellitus
  • Hypertension
  • Hyperthyroidism
  • Sleeping face-down

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Floppy Eyelid Syndrome? (Etiology)

The known causes of Floppy Eyelid Syndrome include:

  • Mechanical trauma:
    • Chronic lid-pillow interaction in facedown sleeping can reduce elastin, resulting in rubbery/loose eyelids
    • Elastin is a protein in connective tissue responsible for maintaining the shape and structure of many tissues in the body after they expand (stretch) or contract
  • Obstructive sleep apnea does not cause Floppy Eyelid Syndrome directly, but there is a strong correlation between the two

What are the Signs and Symptoms of Floppy Eyelid Syndrome?

The symptoms of Floppy Eyelid Syndrome may include:

  • Easily everting (turning inside out), loose, and rubbery upper eyelids
  • Red eyes in the morning upon awakening
  • Chronic corneal inflammation
  • Chronic inflammation of the tissue underneath the upper eyelids, known as superior palpebral conjunctiva
  • Symptoms of obstructive sleep apnea, such as daytime sleepiness and snoring, may be observed

How is Floppy Eyelid Syndrome Diagnosed?

Floppy Eyelid Syndrome is diagnosed by the following methods:

  • An examination of the affected individual’s eyes and an assessment of the presenting symptoms
  • Assessing the individual’s sleeping habits, such as favored position of sleeping, difficulty sleeping, daytime sleepiness, and snoring
  • An evaluation of detailed medical history that includes obstructive sleep apnea and other underlying medical conditions

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Floppy Eyelid Syndrome?

Some possible complications of Floppy Eyelid Syndrome include:

  • Keratoconus, where the cornea forms conical in shape, if caused by chronic eye rubbing
  • Chronic papillary conjunctivitis: Easy lid eversion while sleeping exposes the conjunctiva underneath the upper eyelids, resulting in chronic inflammation
  • Punctate epithelial erosions: Superficial corneal inflammation due to air exposure while sleeping from poor eyelid function
  • Exposure keratopathy: It is a more severe, chronic, corneal inflammation due to air exposure while sleeping from poor eyelid function
  • Dry eye syndrome: Normal blinking produces a fresh set of tears on the ocular surface; poor eyelid function from Floppy Eyelid Syndrome makes this process less efficient

How is Floppy Eyelid Syndrome Treated?

The treatment options for Floppy Eyelid Syndrome may involve:

  • Addressing and treating associated medical conditions, such as obstructive sleep apnea, as well as other conditions
  • Extensive application of lubricating ointment to the eye at bedtime to protect the ocular surface from being exposed while sleeping
  • Taping of the eyelids at bedtime to prevent lid eversion while sleeping
  • Eye patching or shielding at bedtime to prevent conjunctiva and corneal exposure while sleeping
  • Surgical intervention, including shortening or tightening the eyelids

How can Floppy Eyelid Syndrome be Prevented?

The following tips may help prevent the occurrence of Floppy Eyelid Syndrome:

  • Proper diet and exercise to manage obesity
  • Sleeping on one’s side or back to prevent mechanical trauma to the eye, from lid-pillow contact
  • Effective management of obstructive sleep apnea

What is the Prognosis of Floppy Eyelid Syndrome? (Outcomes/Resolutions)

  • The prognosis of Floppy Eyelid Syndrome can be poor, due to the loss of elastin within the tarsal plate (connective tissue involving the eyelids)
  • However, the complications of FES can be addressed effectively and further damage avoided, if the condition is diagnosed early and steps are taken to treat any underlying medical conditions (such as obstructive sleep apnea)

Additional and Relevant Useful Information for Floppy Eyelid Syndrome:

  • In general, Floppy Eyelid Syndrome is an under-diagnosed condition
  • There is a strong association between increased severity of the condition of one eye compared to the other and the side of the face most often slept upon

What are some Useful Resources for Additional Information?

References and Information Sources used for the Article:

Helpful Peer-Reviewed Medical Articles:

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: Jan. 30, 2017
Last updated: Sept. 14, 2018