Survey of Ophthalmology
Volume 55, Issue 1 , Pages 35-46 , January 2010

Floppy Eyelid Syndrome: Stretching the Limits

  • Daniel G. Ezra, MA, MRCS, MRCOphth

      Affiliations

    • Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
    • Department of Cell Biology, UCL Institute of Ophthalmology, London, United Kingdom
    • NIHR Biomedical Research Center for Ophthalmology, Moorsfields Eye Hospital and UCL Institute of Ophthalmology, Moorsfields Eye Hospital, London, United Kingdom
    • Corresponding Author InformationReprint address: Mr. Daniel G Ezra, MA, MRCS, MRCOphth, Adnexal Department, Moorfields Eye Hospital, City Road, London EC1V 2PD, United Kingdom.
  • ,
  • Michèle Beaconsfield, FRCS, FRCOphth

      Affiliations

    • Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
  • ,
  • Richard Collin, MA, FRCS, FRCOphth

      Affiliations

    • Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom

References 

  1. Abdal H, Pizzimenti JJ, Purvis CC. The eye in sleep apnea syndrome. Sleep Med. 2006;7(2):107–115
  2. Alexandrakis G, Tse DT, Chang WJ. Spontaneous globe luxation associated with floppy eyelid syndrome and shallow orbits. Arch Ophthalmol. 1999;117(1):138–139
  3. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97(11):2192–2196
  4. Apostolopoulos M, Papaspirou A, Damanakis A, et al. Bilateral optic neuropathy associated with voluntary globe luxation and floppy eyelid syndrome. Arch Ophthalmol. 2004;122(10):1555–1556
  5. Archambault J, Tsuzaki M, Herzog W, Banes AJ. Stretch and interleukin-1beta induce matrix metalloproteinases in rabbit tendon cells in vitro. J Orthop Res. 2002;20(1):36–39
  6. Arocker-Mettinger E, Haddad R, Konrad K, Steinkogler FJ. [Floppy eyelid syndrome: light and electron microscopy studies]. Klin Monatsbl Augenheilkd. 1986;188(6):596–598
  7. Barros EM, Rodrigues CJ, Rodrigues NR, et al. Aging of the elastic and collagen fibers in the human cervical interspinous ligaments. Spine J. 2002;2(1):57–62
  8. Bilenchi R, Poggiali S, Pisani C, et al. M Floppy eyelid syndrome associated with obstructive sleep apnoea. Br J Dermatol. 2004;151(3):706
  9. Bouchard CS. Lateral tarsorrhaphy for a noncompliant patient with floppy eyelid syndrome. Am J Ophthalmol. 1992;114(3):367–369
  10. Boulton JE, Sullivan TJ. Floppy eyelid syndrome and mental retardation. Ophthalmology. 2000;107(11):1989–1991
  11. Brown MD, Potter JW. Floppy eyelid syndrome: a case report and clinical review. J Am Optom Assoc. 1992;63(5):309–314
  12. Burkat CN, Lemke BN. Acquired lax eyelid syndrome: an unrecognized cause of the chronically irritated eye. Ophthal Plast Reconstr Surg. 2005;21(1):52–58
  13. Culbertson WW, Ostler HB. The floppy eyelid syndrome. Am J Ophthalmol. 1981;92(4):568–575
  14. Culbertson WW, Tseng SC. Corneal disorders in floppy eyelid syndrome. Cornea. 1994;13(1):33–42
  15. Da Pra A, Brunzini M, Croxatto JO, Nano H. [Floppy eyelid syndrome. 5 cases]. Ophtalmologie. 1989;3(4):314
  16. Dhillon S, Shapiro CM, Flanagan J. Sleep-disordered breathing and effects on ocular health. Can J Ophthalmol. 2007;42(2):238–243
  17. Di Pascuale MA, Espana EM, Liu DT, et al. Correlation of corneal complications with eyelid cicatricial pathologies in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis syndrome. Ophthalmology. 2005;112(5):904–912
  18. Diller R, Sant S. A case report and review of filamentary keratitis. Optometry. 2005;76(1):30–36
  19. Donnenfeld ED, Perry HD, Gibralter RP, et al. Keratoconus associated with floppy eyelid syndrome. Ophthalmology. 1991;98(11):1674–1678
  20. Downes RN, Mininni F, Collin JRO, et al. Floppy eyelid syndrome in pachydermoperiostosis. Orbit. 1989;8(2):93–99
  21. Dufek MA, Shechtman DL. Floppy eyelid syndrome: a diagnostic dilemma. J Am Optom Assoc. 1999;70(7):450–454
  22. Dutton JJ. Surgical management of floppy eyelid syndrome. Am J Ophthalmol. 1985;99(5):557–560
  23. Easterbrook M. Floppy eyelid syndrome. Can J Ophthalmol. 1985;20(7):264–265
  24. Eiferman RA, Gossman MD, O'Neill K, Douglas CH. Floppy eyelid syndrome in a child. Am J Ophthalmol. 1990;109(3):356–357
  25. English FP, Nutting WB. Demodicosis of ophthalmic concern. Am J Ophthalmol. 1981;91(3):362–372
  26. Ezra DG, Derriman L, Mellingtion FE, et al. Spontaneous globe luxation associated with shallow orbits and floppy eyelid syndrome. Orbit. 2008;27(1):55–58
  27. Fleishman JA, Hoffman RO. An unusual case of floppy eyelid syndrome. Ann Ophthalmol. 1988;20(12):468–469
  28. Gao J, Crapo P, Nerem R, Wang Y. Co-expression of elastin and collagen leads to highly compliant engineered blood vessels. J Biomed Mater Res A. 2008;85(4):1120–1128
  29. Gardner K, Arnoczky SP, Caballero O, Lavagnino M. The effect of stress-deprivation and cyclic loading on the TIMP/MMP ratio in tendon cells: an in vitro experimental study. Disabil Rehabil. 2008;30(20–22):1523–1529
  30. Gerner EW, Hughes SM. Floppy eyelid with hyperglycinemia. Am J Ophthalmol. 1984;98(5):614–616
  31. Goldberg R, Seiff S, McFarland J, et al. Floppy eyelid syndrome and blepharochalasis. Am J Ophthalmol. 1986;102(3):376–381
  32. Goldberg RA, Coden DJ, Hornblass A, Mitchell JP. Floppy eyelid syndrome associated with marked lower eyelid ectropion. Am J Ophthalmol. 1989;108(5):610–612
  33. Gonnering RS, Sonneland PR. Meibomian gland dysfunction in floppy eyelid syndrome. Ophthal Plast Reconstr Surg. 1987;3(2):99–103
  34. Gross RH, Mannis MJ. Floppy eyelid syndrome in a child with chronic unilateral conjunctivitis. Am J Ophthalmol. 1997;124(1):109–110
  35. Holbach LM. Diseases of the eyelid-conjunctival complex and corneal complications of lid disease. Curr Opin Ophthalmol. 1995;6(4):39–43
  36. Huber-Spitzy V, Grabner G, Stur M. [Syndrome of the flaccid eyelid (floppy eyelid syndrome)]. Klin Monatsbl Augenheilkd. 1984;185(4):289–291
  37. Imbert P, Williamson W, Leger F, et al. [Bilateral corneal neovascularization and floppy eyelid syndrome. A case report]. J Fr Ophtalmol. 1990;13(4):223–225
  38. Iyengar SS, Khan JA. Quantifying upper eyelid laxity in symptomatic floppy eyelid syndrome by measurement of anterior eyelid distraction. Ophthal Plast Reconstr Surg. 2007;23(3):255
  39. Kakizaki H, Zako M, Miyaishi O, et al. The lacrimal canaliculus and sac bordered by the Horner's muscle form the functional lacrimal drainage system. Ophthalmology. 2005;112(4):710–716
  40. Karesh JW, Nirankari VS, Hameroff SB. Eyelid imbrication. An unrecognized cause of chronic ocular irritation. Ophthalmology. 1993;100(6):883–889
  41. Karger RA, White WA, Park WC, et al. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Ophthalmology. 2006;113(9):1669–1674
  42. 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;248:61–66
  43. Kielty CM, Sherratt MJ, Shuttleworth CA. Elastic fibres. J Cell Sci. 2002;115(Pt 14):2817–2828
  44. Klapper SR, Jordan DR. Floppy eyelid syndrome. Ophthalmology. 1998;105(9):1582
  45. Langford JD, Linberg JV. A new physical finding in floppy eyelid syndrome. Ophthalmology. 1998;105(1):165–169
  46. Lee WJ, Kim JC, Shyn KH. Clinical evaluation of corneal diseases associated with floppy eyelid syndrome. Korean J Ophthalmol. 1996;10(2):116–121
  47. Leger F, Vital C, Negrier ML, Bloch B. Histologic findings in a series of 1,540 corneal allografts. Ann Pathol. 2001;21(1):6–14
  48. Leibovitch I, Selva D. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Med. 2006;7(2):117–122
  49. Lemke BN, Sires BS, Dortzbach RK. A tarsal strip-periosteal flap technique for lateral canthal fixation. Ophthalmic Surg Lasers. 1999;30(3):232–236
  50. Lemke BN, Cook BE, Lucarelli MJ. Canthus-sparing ectropion repair. Ophthal Plast Reconstr Surg. 2001;17(3):161–168
  51. Liu DT, Di Pascuale MA, Sawai J, et al. Tear film dynamics in floppy eyelid syndrome. Invest Ophthalmol Vis Sci. 2005;46(4):1188–1194
  52. Mack WP. Floppy eyelid syndrome and mental retardation. Ophthalmology. 2001;108(12):2159–2160
  53. Madjlessi F, Kluppel M, Sundmacher R. [Operation of the floppy eyelid. Symptomatic cases require surgical eyelid stabilization]. Klin Monatsbl Augenheilkd. 2000;216(3):148–151
  54. Mastrota KM. Impact of floppy eyelid syndrome in ocular surface and dry eye disease. Optom Vis Sci. 2008;85(9):814–816
  55. Mazal Z. [The floppy eyelid syndrome]. Cesk Oftalmol. 1990;46(6):434–438
  56. McMonnies CW. The evidentiary significance of case reports: eye rubbing and keratoconus. Optom Vis Sci. 2008;85(4):262–269
  57. McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg. 1997;13(2):98–114
  58. McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea. Clin Experiment Ophthalmol. 2000;28(2):125–126
  59. McNab AA. The eye and sleep. Clin Experiment Ophthalmol. 2005;33(2):117–125
  60. McNab AA. The eye and sleep apnea. Sleep Med Rev. 2007;11(4):269–276
  61. Mills DM, Meyer DR, Harrison AR. Floppy eyelid syndrome: quantifying the effect of horizontal tightening on upper eyelid position. Ophthalmology. 2007;114(10):1932–1936
  62. Mojon DS, Goldblum D, Fleischhauer J, et al. Eyelid, conjunctival, and corneal findings in sleep apnea syndrome. Ophthalmology. 1999;106(6):1182–1185
  63. Moore MB, Harrington J, McCulley JP. Floppy eyelid syndrome. Management including surgery. Ophthalmology. 1986;93(2):184–188
  64. Mortemousque B, Williamson W, Poirier L. [Floppy eyelid syndrome. Apropos of 4 cases and review of the literature]. J Fr Ophtalmol. 1995;18(8–9):542–547
  65. Mullner-Eidenbock A, Moser E, Klebermass N. Ocular features of the congenital cataracts facial dysmorphism neuropathy syndrome. Ophthalmology. 2004;111(7):1415–1423
  66. Negris R. Floppy eyelid syndrome associated with keratoconus. J Am Optom Assoc. 1992;63(5):316–319
  67. Netland PA, Sugrue SP, Albert DM, Shore JW. Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology. 1994;101(1):174–181
  68. Otto H, Boke W. [Papillary conjunctivitis in floppy eyelid syndrome––a case report]. Fortschr Ophthalmol. 1986;83(4):410–411
  69. Paciuc M, Mier ME. A woman with the floppy eyelid syndrome. Am J Ophthalmol. 1982;93(2):255–256
  70. Pacuic M. Floppy eyelid with hyperglycinemia. Am J Ophthalmol. 1985;99(5):619–620
  71. Parunovic A. Floppy eyelid syndrome. Br J Ophthalmol. 1983;67(4):264–266
  72. Parunovic A, Ilic B. Floppy eyelid syndrome associated with keratoconus. Br J Ophthalmol. 1988;72(8):634–635
  73. Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthal Plast Reconstr Surg. 2002;18(5):370–372
  74. Pham TT, Perry JD. Floppy eyelid syndrome. Curr Opin Ophthalmol. 2007;18(5):430–433
  75. Price EB, Silliphant WM, Shuman R. Nodular fasciitis: a clinicopathologic analysis of 65 cases. Am J Clin Pathol. 1961;35:122–136
  76. Rao LG, Bhandary SV, Devi AR, Gangadharan S. Floppy eyelid syndrome in an infant. Indian J Ophthalmol. 2006;54(3):217–218
  77. Rapoza PA, Quinn TC, Terry AC, et al. A systematic approach to the diagnosis and treatment of chronic conjunctivitis. Am J Ophthalmol. 1990;109(2):138–142
  78. Reifler DM. Floppy eyelids and crack eye syndrome. Ophthalmology. 1993;100(7):975
  79. Reyniers R, Paridaens D. Spontaneous globe luxation and floppy eyelid syndrome in a patient with Hashimoto's disease. Eye. 2007;21(2):303–304
  80. Robert PY, Adenis JP, Tapie P, Melloni B. Eyelid hyperlaxity and obstructive sleep apnea (OSA) syndrome. Eur J Ophthalmol. 1997;7(3):211–215
  81. Rossiter JD, Ellingham R, Hakin KN, Twomey JM. Corneal melt and perforation secondary to floppy eyelid syndrome in the presence of rheumatoid arthritis. Br J Ophthalmol. 2002;86(4):483
  82. Samaha AN, Farah NT, Maaluf R. Floppy eyelid syndrome in a child with vernal catarrh. J Pediatr Ophthalmol Strabismus. 1999;36(4):216–218
  83. Schlotzer-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;112(4):694–704
  84. Scholten E, Marck KW, Grond AJ. Surgical correction of floppy eyelids. Br J Plast Surg. 1998;51(3):264–266
  85. Schwartz LK, Gelender H, Forster RK. Chronic conjunctivitis associated with ‘floppy eyelids’. Arch Ophthalmol. 1983;101(12):1884–1888
  86. Segev F, Heon E, Cole WG, et al. Structural abnormalities of the cornea and lid resulting from collagen V mutations. Invest Ophthalmol Vis Sci. 2006;47(2):565–573
  87. Seiff SR. Surgical management of seventh nerve paralysis and floppy eyelid syndrome. Curr Opin Ophthalmol. 1999;10(4):242–246
  88. Shah-Desai S, Sandy C, Collin R. Lax eyelid syndrome or ‘progeria’ of eyelid tissues. Orbit. 2004;23(1):3–12
  89. Smolin G. Meetings, conferences, symposia. Am J Ophthalmol. 1982;93(2):249
  90. Spencer WHZL. Conjunctiva, in Spencer WH. In: Ophthalmic Pathology, an Atlas and Textbook. Philadelphia, PA: WB Saunders Co.; 1985;p. 600;ed. 3
  91. Stone DU, Chodosh J. Epibulbar nodular fasciitis associated with floppy eyelids. Cornea. 2005;24(3):361–362
  92. Taban M, Perry JD. Plasma leptin levels in patients with floppy eyelid syndrome. Ophthal Plast Reconstr Surg. 2006;22(5):375–377
  93. Tanenbaum M. A rational approach to the patient with floppy/lax eyelids. Br J Ophthalmol. 1994;78(9):663–664
  94. Tenzel RR, Buffam FV, Miller GR. The use of the “lateral canthal sling” in ectropion repair. Can J Ophthalmol. 1977;12(3):199–202
  95. Valenzuela AA, Sullivan TJ. Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: a new surgical approach. Ophthal Plast Reconstr Surg. 2005;21(4):259–263
  96. van den Bosch WA, Lemij HG. The lax eyelid syndrome. Br J Ophthalmol. 1994;78(9):666–670
  97. van Nouhuys H, van den Bosch WA, Lemij HJ, Mooy CM. Floppy eyelid syndrome associated with demodex brevis. Orbit. 1994;13(3):125–129
  98. Viana GA, Sant'Anna AE, Righetti F, Osaki M. Floppy eyelid syndrome. Plast Reconstr Surg. 2008;121(5):333e–334e
  99. Whitnall SE. Anatomy of the Human Orbit and Accessory Organs of Vision. London: Henry Frowde and Hodder and Stoughton; 1921;
  100. Woog JJ. Obstructive sleep apnea and the floppy eyelid syndrome. Am J Ophthalmol. 1990;110(3):314–315

 This review forms part of a thesis for the degree of Doctor of Medicine submitted to Cambridge University. This study was funded by the special trustees of Moorfields Eye Hospital. The authors acknowledge a proportion of their financial support from the Department of Health through the award made by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology. The views expressed in this publication are those of the authors and not necessarily those of the Department of Health.The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

PII: S0039-6257(09)00139-8

doi: 10.1016/j.survophthal.2009.02.025

Survey of Ophthalmology
Volume 55, Issue 1 , Pages 35-46 , January 2010