Speaker: Suspect sleep apnea in all cases of floppy eyelid syndrome

ATLANTA – Essentially 100% of patients with floppy eyelid syndrome have obstructive sleep apnea, according to a speaker here at SECO.

“Sleep apnea is almost becoming a public health epidemic in the U.S., mainly due to our status as an overweight country,” Brad Sutton, OD, FAAO, of Indiana University School of Optometry, said at a continuing education session partially sponsored by Primary Care Optometry News.

Eighty percent of men and 90% of women who suffer from sleep apnea are undiagnosed, Sutton said.

“I can’t stress this enough: when you have your medical intake forms, review of systems, sleep apnea needs to be on that form,” he said. “Patients won’t offer that unless there’s a place to put it. They don’t think about this if it doesn’t neatly fit into another category that may be on the list.”

The incidence of sleep apnea in patients with floppy eyelid syndrome (FES) is “essentially 100%,” Sutton said.

In FES, the eyelids become loose and rubbery, Sutton said, and evert with little pressure.

“It’s a result of the chronic flipping of those lids during sleep,” he said.

FES is associated with keratoconus as well as lash ptosis.

“Thankfully, if you control the sleep apnea, the FES tends to improve,” Sutton said. “We don’t know exactly how they’re related, maybe metalloproteinase; we’re not sure. The lid contacts the pillow and partially opens or flips open.

“I can’t stress how incredibly underdiagnosed this is,” he continued. “You’ll see patients come in with several bottles of drops and say they’ve seen lots of practitioners and they don’t feel better.”

Sutton described the diagnostic technique for FES: pull the eyebrows up and have the patient look down; the upper lids will evert.

“Evaluate their lashes; if they point downward, that’s an indication,” he said.

Patients will describe their symptoms as waking up with a dry, gritty, irritated eye that gets better during the day, Sutton said. They may have punctate keratitis, conjunctivitis and mucous discharge.

Sutton urges his patients with FES to get tested for sleep apnea.

He described his three-prong treatment approach: use a thicker lubricating ointment at night; sleep with a cylindrical pillow to prevent mechanical contact of the eye with the pillow; wear a firm sleep mask to prevent lid eversion.

Most patients resist taping their lids, so Sutton recommends cutting a Breathe Right strip up the middle and using half on each eye.

“Patients comply well with this,” he said.

The “end game,” as Sutton said, is surgical resection of the eyelid tissue to tighten it.