Description

An obese 44-year-old man, a smoker, with a body mass index (BMI) of 38 and a history of diabetes, had multiple presentations of a left red eye with associated tearing, burning, itching and gritty feeling. He was treated for bacterial conjunctivitis on many occasions in the primary care setting before being referred to the ophthalmology department. On closer examination, chronic papillary conjunctivitis was noted, with increased eyelid laxity (figure 1).

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Figure 1

(A and B)Hyperlaxity of the left eyelid with simple traction.

These findings were characteristic of floppy eyelid syndrome (FES), an underdiagnosed condition commonly seen in obese middle-aged men and strongly associated with obstructive sleep apnoea (OSA).1

The patient also reported of snoring and daytime sleepiness on further questioning. His Epworth Sleepiness Score was 20/24, and the Apnoea/Hypopnoea Index was 32, based on the polysomnography, which indicated severe OSA.

Ocular management was conservative with lubricating ointment and included taping the eyelid shut at night, while continuous positive airway pressure combined with weight loss and smoking cessation improved the OSA symptoms.

Hyperlaxity of the eyelids results in easy eversion on gentle pressure due to loose, rubbery tarsal plates of the eyelids, commonly occurring when patients are asleep face down against a pillow (figure 2). This leads to tear film disorders and chronic conjunctivitis, resulting in the aforementioned symptoms, either unilaterally or bilaterally.2

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Figure 2

Spontaneous left upper eyelid eversion (arrow) when a patient is asleep face down against a pillow.

Management is usually conservative, while surgical intervention is reserved for severe cases.3 Referral to a sleep physician should be considered in such cases.