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Floppy Eyelid Syndrome

Viana, Giovanni André P. M.D.; Sant’Anna, Ana Estela M.D.; Righetti, Fábio M.D.; Osaki, Midori M.D.

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Plastic and Reconstructive Surgery: May 2008 - Volume 121 - Issue 5 - p 333e-334e
doi: 10.1097/PRS.0b013e31816b1147
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The floppy eyelid syndrome was initially described by Culbertson and Ostler1 in 1981 in 11 obese, middle-aged men. Although initially reported in obese men,1 this syndrome may also occur in women.2,3 It is an often-misdiagnosed disorder with unknown pathogenesis that is characterized by an easily everted upper eyelid, a soft and foldable tarsus, and a chronic papillary conjunctivitis of the upper eyelid conjunctiva.1 Several systemic conditions have been reported in association with floppy eyelid syndrome, most commonly obesity (43 percent), hypertension (13 percent), diabetes mellitus (12 percent), and obstructive sleep apnea (6 percent).1,3 In obese patients, there is frequently a history of sleeping on the affected side, which suggests that chronic eyelid eversion may cause mechanical damage to the tarsus1,2; eye rubbing also may be associated.2 We report our findings and experience in five consecutive cases of floppy eyelid syndrome treated at the Federal University of São Paulo during 2005.

Four of the five patients were male. Patient ages ranged from 42 to 62 years (mean, 50 years). Two patients presented with bilateral disease, and three presented with unilateral disease (right, n = 1; left, n = 2). The main presenting complaints included eyelid swelling, foreign body sensation, pain, and tearing. All patients had spontaneous eyelid eversion and a pliant upper tarsus. Another clinical finding was blepharoptosis in two patients, who had classic signs of aponeurotic ptosis. All patients studied presented obesity as an associated systemic condition.

All patients underwent a surgical procedure. In seven upper eyelids, a lateral tarsal strip without periostal flap for lateral canthal fixation was used, in association with lower eyelid correction in four cases; all patients had a bilateral lower eyelid lateral tarsal strip.

All patients had complete resolution of symptoms and normalization of eyelash position after surgery, with a stable and good cosmetic appearance after a mean follow-up of 6 months (Fig. 1). Patients were instructed to return if preoperative symptoms recurred.

Fig. 1.
Fig. 1.:
(Above) Preoperative appearance; upper eyelid distraction. (Below) One-year postoperative appearance.

There is a well-documented association of this syndrome with keratoconus, and it was identified in one patient in this series.2 There was one case of meibomian gland inflammation with qualitative abnormality of tear film, which, combined with nocturnal exposure and poor contact of the lax eyelid with the globe, may have contributed to the keratoconjunctivitis found in this syndrome.

Effective treatments for this syndrome have been described. They include nocturnal eye shields, taping of the eyelids during sleep, and surgical tightening of the affected side, such as pentagonal upper eyelid wedge resection beginning at the lateral third of the eyelid, lateral tarsorrhaphy, modified back-tapered wedge resection with advancement flap, the Bick procedure, lateral tarsal strip with or without a periosteal flap for lateral canthal fixation, in association with lower eyelid correction in certain cases, and medial upper eyelid shortening to correct medial eyelid laxity.1,4,5

We believe that surgical treatment is the best management choice; however, clinic management is still a reasonable option for those patients who do not want to undergo a surgical procedure.

Giovanni André P. Viana, M.D.

Ana Estela Sant’Anna, M.D.

Fábio Righetti, M.D.

Midori Osaki, M.D.

Oculoplastic Surgery Service

Department of Ophthalmology

Federal University of São Paulo

São Paulo, Brazil


The authors hereby certify that, to the best of their knowledge, no financial support or benefits have been received the senior or any co-author, by any member of their immediate family or any individual or entity with whom or with which they have a significant relationship from any commercial source that is related directly or indirectly to the scientific work that is reported on in the communication except as described below. They understand an example of such a financial interest would be a stock interest in any business entity that is included in the subject matter of the communication or that sells a product relating to the subject matter of the communication.


1. Culbertson, W. W., and Ostler, H. B. The floppy eyelid syndrome. Am. J. Ophthalmol. 92: 568, 1981.
2. Donnenfeld, E. D., Perry, H. D., Gilbralter, R., et al. Keratoconus associated with floppy eyelid syndrome. Ophthalmology 98: 1674, 1991.
3. Langford, J. D., and Linberg, J. V. A new physical finding in floppy eyelid syndrome. Ophthalmology 105: 165, 1998.
4. Valenzuela, A. A., and Sullivan, T. J. Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: A new surgical approach. Ophthalmic Plast. Reconstr. Surg. 21: 259, 2005.
5. Burkat, C. N., and Lemke, B. N. Acquired lax eyelid syndrome: An unrecognized cause of the chronically irritated eye. Ophthalmic Plast. Reconstr. Surg. 21: 52, 2005.

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