Sleep Medicine xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Sleep Medicine

journal homepage: www.elsevier .com/locate /s leep

Floppy eyelid syndrome in obstructive sleep apnea syndrome

Valentín Huerva a,b,⇑, M. Jesús Muniesa a,b, Francisco J. Ascaso c,d

a Department of Ophthalmology, Universitary Hospital Arnau de Vilanova, Lleida, Spainb IRB-Lleida, Lleida, Spainc Department of Ophthalmology, ‘Lozano Blesa’ University Clinic Hospital, Zaragoza, Spaind Aragon Health Sciences Institute, Zaragoza, Spain

a r t i c l e i n f o

Article history:Received 1 September 2013Received in revised form 14 December 2013Accepted 19 December 2013Available online xxxx

Keywords:Floppy eyelidSleep apneaChronic conjunctivitisLax eyelidTearingEye redness

1. Introduction

A 62-year-old man presented with complaints of foreign bodysensation, burning, tearing and redness in both eyes. An easy ever-sion of the upper eyelids was accomplished with minimal manip-ulation (Fig. 1A). Another 70-year-old man presented withsimilar symptoms. A spontaneous eversion of the right upper eye-lid was observed when he closed his eyes (Fig. 1B). Both patientswere previously diagnosed with obstructive sleep apnea syndrome(OSAS).

2. Image analysis

Both cases correspond with floppy eyelid syndrome (FES). Diag-nosis of FES is straightforward. The two basic maneuvers include:complete eversion of the upper eyelids while applying slight trac-tion, and spontaneous eversion of the upper eyelids while closingthe eyes. The hyperlaxity and the nocturnal eyelid eversion may

http://dx.doi.org/10.1016/j.sleep.2013.12.0171389-9457/� 2014 Elsevier B.V. All rights reserved.

⇑ Corresponding author at: Department of Ophthalmology, Universitary HospitalArnau de Vilanova, Avda. Alcade Rovira Roure 80, 25198 Lleida, Spain. Tel.: +34 973705306; fax: +34 973 248754.

E-mail address: vhuerva@gmail.com (V. Huerva).

Please cite this article in press as: Huerva V et al. Floppy eyelid syndrome in10.1016/j.sleep.2013.12.017

lead to ocular surface and tear film disorders and therefore achronic conjunctivitis with the above-mentioned symptomatology.

3. Discussion

FES is an often forgotten and underdiagnosed entity characterizedby flaccid and easily everted upper lids, occurring spontaneously orwith minimal manipulation. It is usually seen in overweight, middle-aged males who complain of a foreign body sensation, burning, tear-ing and redness. Some studies have found an interesting associationwith OSAS [1,2]. This relationship may have both diagnostic andtherapeutic implications. Nevertheless, the majority of OSASpatients, obese or non-obese, do not have FES. Furthermore, FESmay also be a presenting symptom in patients with undiagnosedOSAS [2]. Although the cause remains unknown, in all probabilityOSAS has no real causative relationship, other than a sequence ofextreme apnea, right heart failure, and increased venous pressurethat worsens a propensity for this phenomenon.

Additionally, treatment of obesity and OSAS may have a favour-able effect on the course of FES [3]. The clinician should be awareof this association so that both underlying OSAS or FES can bedetected.

Fig. 1. Easy diagnosis of floppy eyelid syndrome with few simple maneuvers. (A)Complete eversion of lids with simple traction. (B) Spontaneous eversion of theright upper eyelid while closing the eyes.

obstructive sleep apnea syndrome. Sleep Med (2014), http://dx.doi.org/

2 V. Huerva et al. / Sleep Medicine xxx (2014) xxx–xxx

The condition should be suspected in any obese patient withchronic watery and red eyes. Besides weight loss and continuouspositive airway pressure therapy if OSAS is suspected, treatmentconsists of supportive measures such as ocular lubrication, eyelidtaping, or an eyeshield at bedtime to keep the eyelids closed whilesleeping, and surgery to address horizontal laxity and redundanteyelid tissues.

Funding sources

None.

Please cite this article in press as: Huerva V et al. Floppy eyelid syndrome in10.1016/j.sleep.2013.12.017

Conflict of interest

The ICMJE Uniform Disclosure Form for Potential Conflicts ofInterest associated with this article can be viewed by clicking onthe following link: http://dx.doi.org/10.1016/j.sleep.2013.12.017.

References

[1] Abdal H, Pizzimenti JJ, Purvis CC. The eye in sleep apnea syndrome. Sleep Med2006;7:107–15.

[2] Leibovitch I, Selva D. Floppy eyelid syndrome: clinical features and theassociation with obstructive sleep apnea. Sleep Med 2006;7:117–22.

[3] McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructivesleep apnea. Clin Exp Ophthalmol 2000;28:125–6.

obstructive sleep apnea syndrome. Sleep Med (2014), http://dx.doi.org/