Medical Student Notebook: Floppy Eyelid Syndrome and Obstructive Sleep Apnea

| May 1, 2022

by Sandy Samuel, BA 

Ms. Samuel is a medical student at Harvard Medical School in Boston, Massachusetts.

Funding: No funding was provided for this article.

Disclosures: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(5):10–11.


Abstract

Floppy eyelid syndrome (FES) is defined by eyelid hyperlaxity that results in a range of ocular sequalae, including significant eye irritation. FES is known to be associated with obstructive sleep apnea (OSA). Several histopathological changes, including increased expression of elastin-degrading enzymes, have been noted in FES. Conservative treatment includes use of eye shields, eyelid taping, and use of topical lubricants. Patients with OSA may also experience improvement in their ocular symptoms after long-term use of continuous positive airway pressure. There are very limited studies that explore the role of weight loss on FES symptoms. Understanding the clinical presentation of FES can be particularly relevant to the bariatric population, as it can allow for early detection and management of this often underdiagnosed condition. 

Keywords:  Floppy eyelid syndrome, obstructive sleep apnea


Floppy eyelid syndrome (FES) is a condition where the upper eyelids flip upward when the patient is asleep. This results in exposing the conjunctiva and the cornea. This condition was first described in 1981.1 The prevalence of FES among adults ranges from 4 to 16 percent, with a strong male predominance.2 Patients with FES have a wide range of ophthalmic pathologies, including ptosis, papillary conjunctivitis, and glaucoma. Notably, FES is associated with various obesity-related disorders, including hypertension and obstructive sleep apnea (OSA). Given that a significant number of patients with obesity have OSA, the topic of floppy eyelid syndrome becomes relevant to the bariatric population, particularly when considering management of this syndrome. To raise clinical awareness of this common syndrome, this column reviews the pathophysiology, clinical consequences, and management of floppy eyelid syndrome. 

Associated Conditions 

Many studies have previously established an association between FES and OSA. In fact, the prevalence of OSA amongst patients with FES has been reported to be up to 100 percent.2 

However, studies that specifically examine the relationship between obesity and FES have generated mixed results. A study by Beis et al3 demonstrated a statistically significant association between eyelid hyperlaxity and patients with OSA and high body mass index (BMI), compared to those with a low BMI. Interestingly, the findings of this study did not elucidate a relationship between obesity and FES. Other studies have argued that both FES and OSA are independently associated with obesity.4 Hence, it is unclear if there is a causal relationship between OSA and FES or if they simply share common risk factors. 

Pathophysiology

There have been multiple hypotheses proposed to explain the pathogenesis of FES. Histologic studies examining eyelids of patients with FES have shown a loss of elastin fibers with increased expression of elastolytic proteases, such as matrix metalloproteinases (MMP).1 These histological features are presumed to be related to mechanical stress and ischemia/reperfusion injuries that occur when a patient lies on their side or in a prone position. In addition to focal pressure ischemia, patients with OSA can experience intermittent systemic hypoxia during episodes of apnea/hypopnea, which could contribute to the aforementioned changes. Furthermore, patients with OSA are known to have more compliant lateral pharyngeal walls, with histological studies demonstrating an increase in collagen type I and variable expression of MMP.1 Thus, it is likely that similar mechanisms to those that contribute to pharyngeal lateral wall laxity in patients with OSA are also at play in determining palpebral laxity in patients with FES. Additional studies are needed to assess the exact mechanism by which OSA can contribute to FES, as current literature has not fully explored this topic. 

Clinical Consequences 

There is a wide spectrum of ophthalmic involvement in FES. Many patients with FES often have strictly unilateral disease, typically affecting their preferred sleeping side.4 The eyelids, which are designed to protect the ocular surface, are the primary organ affected by FES. The increased eyelid laxity can result in upper eyelid ptosis and blepharochalasis (recurrent bouts of painless nonpitting edema of the upper eyelids).5 Corneal involvement is also commonly cited in the literature, including gross surface scarring and perfusion injuries.5 Patients with FES might endorse a wide range of symptoms, including redness, dry or foreign body sensation, tearing, mucus discharge, and blurry vision, which are typically worse in the morning. These symptoms can be chronic and resistant to dry eye treatmentl, and thus, it is important to assess for FES, particularly in patients with OSA. 

Prevention and Management 

Management of FES involves medical and surgical approaches. Conservative treatment aims at proper positioning of the eyelid against the globe to reduce additional trauma. It is comprised of using topical lubricants and protecting the eyelids during sleep with shields or eyelid taping. In addition, studies by McNab et al6 have shown that treatment of OSA with continuous positive airway pressure (CPAP) resulted in notable improvement in ocular symptoms. These included a reduction in conjunctival changes and lid laxity. Surgical treatment can also be considered when conservative measures provide inadequate symptomatic relief. Resection of the lateral third of the eyelid is one of many procedures that can be performed to correct lid laxity. Nevertheless, some studies have shown significant recurrence rates, varying from 25.6 to 60.6 percent depending on the surgical intervention.7

Weight loss is a key step in the treatment of obesity-related comorbidities, and we hypothesize that it is likely important in improving FES symptoms. However, there is a paucity of literature to our knowledge that assess the effect of weight loss and bariatric surgery on FES symptoms. Hence, more research should be conducted to explore if there is an association between bariatric surgery and FES. 

Conclusion

FES is a common, yet underdiagnosed, condition that can be associated with significant ocular symptoms. It is critical to consider FES when patients with high BMI, particularly those with OSA, present with nonspecific ocular symptoms, such as eye irritation. While the pathogenesis of FES is yet to be fully elucidated, there are clear histological changes that occur in the eyelids that might suggest maladaptive remodeling of underlying connective tissue. Conservative treatment is often the first line approach, with a special consideration in patients with concomitant FES and OSA who might experience an improvement in ocular symptoms after long-term CPAP therapy.

References

  1. Teodor RC, Mihaltan FD. Eyelid laxity and sleep apnea syndrome: a review. Rom J Ophthalmol. 2019;63(1):2–9.
  2. Salinas R, Puig M, Fry CL, et al. Floppy eyelid syndrome: a comprehensive review. Ocul Surf. 2020;18(1):31–39.
  3. Beis PG, Brozou CG, Gourgoulianis KI, et al. The floppy eyelid syndrome: evaluating lid laxity and its correlation to sleep apnea syndrome and body mass index. ISRN Ophthamol. 2012;2012:650892. 
  4. Wang P, Yu DJ, Feng G, et al. Is floppy eyelid syndrome more prevalent in obstructive sleep apnea syndrome patients?. J Ophthalmol. 2016;2016:6980281.
  5. Leibovitch I, Selva D. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Med. 2006;7(2):117–122.
  6. McNab AA. The eye and sleep. Clin Experimental Ophthalmol. 2005;33(2):117–125.
  7. Ezra DG, Beaconsfield M, Sira M, et al. The associations of floppy eyelid syndrome: a case control study. Ophthalmology. 2010;117(4):831–838.

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