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BLOG: Floppy eyelid syndrome can’t get no respect
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When you think about Rodney Dangerfield and dry eye disease — and let’s face it, who doesn’t? — you probably think about exposure, right? Come on — those bulging eyes! With the possible exception of Marty Feldman — all you Millennials should Google “Igor Young Frankenstein” — no one has ever gotten more out of his eyes on stage than Rodney Dangerfield. When I watch old videos of his routines, I want to go up to my TV and put a couple of drops of Refresh on the screen.
Dangerfield’s signature line was, “I tell ya, I can’t get no respect.” That’s what comes to mind when I think about floppy eyelid syndrome. We never think about, it always surprises us when we make the diagnosis, and for the life of us, we don’t really know what to do with it when we do make a diagnosis. Maybe it’s the name: Floppy. Eyelid. Syndrome. Admit it, you can’t take anything named “floppy” seriously. Makes you think about bunny rabbits. It’s a real problem associated with a decrease in the elastic tension of the upper and lower lids. Maybe if it had a more grown-up name like “friction-associated ED.”
Now that’s a catchy name.
Culbertson and Ostler first described floppy eyelid syndrome in 1981. Afflicted patients complain of ocular discomfort, tearing, redness and chronic foreign body sensation, just like so many other ocular surface disease patients. It commonly presents in obese patients (or patients who have just had a major weight loss), and it is strongly associated with obstructive sleep apnea. Patients present with flaccid upper and lower lids that are easily everted, a papillary reaction on the tarsal conjunctiva and punctate corneal staining. Whereas tear osmolarity is variable, the MMP-9 is often markedly positive.
Treating floppy eyelid syndrome is initially supportive. Lubricating ointment at bedtime, with or without taping the lids shut, is step one. The only thing I’ve found helpful for the chronic inflammation is topical steroids; long-term steroid necessity means Lotemax Gel (loteprednol etabonate ophthalmic gel 0.5%, Bausch + Lomb). Treat until symptoms improve. Ultimately these patients require surgery, and extensive surgery at that. There is so much stretching of the “elastic sling” that both a wedge resection and a tarsal strip are usually necessary. Aggressive treatment makes a huge difference in the lives of these patients.
Like Rodney Dangerfield, maybe it’s too much to ask for floppy eyelid syndrome to get some respect, but how about a little love instead? You know, like a floppy-eared bunny. Who doesn’t love bunnies?
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.