666 British3rournal ofOphthalmology 1994; 78: 666-670 ORIGINAL ARTICLES - Clinical science Br J Ophthalmol: first published as 10.1136/bjo.78.9.666 on 1 September 1994. Downloaded from The lax eyelid syndrome Willem A van den Bosch, Hans G Lemij Abstract original description, the affection of all patients The floppy eyelid syndrome (FES) was first was none the less diagnosed as FES. Its cause, described in middle aged, obese men. In later however, remained obscure. descriptions, age and sex were not specifically In this paper, four patients are described who mentioned. Associations of FES with various had several signs and symptoms similar to those other syndromes have been described. The described in FES. All of them had an upper authors question whether all these cases repre- eyelid laxity with varied, albeit clearcut, causes. sent the same, single, syndrome. They suggest We shall question whether the term FES applies, that a clinical picture similar to FES may occur or whether a more general term should be in lax upper eyelids of any cause. Four such adopted. cases are reported here. The authors therefore coin the more general term 'lax eyelid syn- drome'. They suggest using the term 'floppy Case reports eyelid syndrome' uniquely for patients with the classic signs and symptoms. CASE 1 (BrJ Ophthalmol 1994; 78: 666-670) An 86-year-old woman (height 160 cm, weight 51 kg) had presented elsewhere with a history of chronic discharge and irritation ofthe left eye for Culbertson and Ostler first described the floppy more'than a year. The symptoms showed no eyelid syndrome (FES) in 1981.1 The syndrome diurnal variation. She did not report sleeping was characterised by a 'floppy' - that is, easily with the affected side on the pillow, nor had she evertible, upper eyelid, and a papillary con- ever noticed upper eyelid eversion during sleep. junctivitis of the upper palpebral conjunctiva. On examination, her left eye had shown purulent Patients often presented with a long history of discharge, a papillary conjunctivitis, and a dif- irritation and discharge. The syndrome only fuse punctate keratitis. She had contracted a occurred in middle aged, obese men. Unnoticed moderate ectropion of the left lower eyelid. No http://bjo.bmj.com/ eversion of the upper eyelid during sleep was corneal vascularisation had been present. A thought to cause the papillary conjunctivitis. At culture from the conjunctiva had grown first, effective treatment consisted of shielding Staphylococcus aureus. She had been treated with the affected eye at night.' Later, surgical correc- several topical antibiotics. Because of a high tion of upper and, in some cases, lower eyelid intraocular pressure, timolol eyedrops also had laxity by means of full thickness eyelid shorten- been prescribed. Despite several weeks of con- ing proved to be very effective.2" Interestingly, tinued treatment, her symptoms had not on September 27, 2021 by guest. Protected copyright. later papers described similar signs and symp- improved. She was then referred to our toms in young or non-obese patients, or in oculoplastic service, where we corrected her association with various disorders such as kera- lower eyelid ectropion by excising a 7 mm full toconus, sleep apnoea syndrome, Meibomian thickness block from the lateral part ofher eyelid gland dysfunction, and the blepharochalasis syn- margin. Thereafter, her symptoms diminished drome. '" Despite these departures from the markedly. After 2 years, however, the discharge Eye Hospital Rotterdam, Rotterdam, The Netherlands W A van den Bosch H G Lemij Correspondence to: Willem van den Bosch, MD, Eye Hospital Rotterdam, Schiedamsevest 180, 3011 BH Rotterdam, The Netherlands. Fig IA Fig IB Accepted for publication Figure I (A) Case 1 atfirst presentation. The affected left eye is closed. (B) The upper eyelid is pulled laterally. Conjunctival 11 April 1994 changes and severe discharge are visible. The nasal sclera is not visible, owing to laxity ofthe medial canthal tendon. The lax eyelid syndrome 667 Br J Ophthalmol: first published as 10.1136/bjo.78.9.666 on 1 September 1994. Downloaded from Fzg 2A PFig 2B Figure 2 (A) Case 1, I month after excision ofafull thickness block from the left upper eyelid and shortening the posterior lamella ofthe left lower eyelid under a skin muscleflap. (B) When the upper eyelid is lifted, no conjunctival injection is visible. and keratitis of the left eye recurred. This time, been treated with eyelid massage, povidone both the medial canthal tendon and the lateral iodine eyedrops, and eyedrops containing tri- canthal ligament were very lax. Surgical reinser- methoprim and polymyxin B for several months, tion ofboth was performed. This resulted clinic- without any improvement. When we examined ally in a better apposition of both upper and him, the lashes ofthe right upper eyelid showed a lower eyelid against the globe. Within a few ptosis. However, they did not touch the cornea. weeks after the operation her signs and symp- In addition, his right upper and lower eyelid toms improved dramatically. Two years later, at proved to be very lax (Fig 3). age 90, she presented for the third time with There was no excessive laxity of the medial severe discharge and a diffuse punctate keratitis canthal tendon or ofthe lateral canthal ligament. (Fig 1). The eyelid laxity appeared to be due to the On examination, she showed a recurrence of combined effects of involutional changes of the the laxity ofhermedial canthal tendon and lateral tarsal plate and to an age-related enophthalmos canthal ligament. We treated her upper eyelid caused by atrophy of orbital fat. On eversion of laxity by removing an 11 mm full thickness block the upper eyelid, the tarsal plate had a normal from the temporal part of the lid. To treat her consistency. A moderate papillary conjunctivitis lower eyelid laxity, we excised a block of pos- ofthe tarsal conjunctiva was present. He also had terior lamella in the lateral canthal angle under a an ulcerative blepharitis. There was a slight skin muscle flap. In the following weeks, the injection ofthe bulbar conjunctiva, together with discomfort, keratitis, and discharge disappeared. a diffuse punctate keratitis. The upper eyelid A slight left upper eyelid ptosis remained. She laxity was corrected by excision of a 15 mm full has been free of the symptoms for 6 months thickness block ofthe temporal part ofthe lid and http://bjo.bmj.com/ (Fig 2). the lower eyelid laxity was treated by excision ofa Histology of the excised upper eyelid block 5 mm full thickness block in the lateral canthal showed severe, active, and chronic conjunctivitis angle. Two weeks after surgery, the patient was with bacterial colonies on the conjunctival sur- free ofthe symptoms. The punctate keratitis and face. The tarsal plate showed moderate to severe the blepharitis disappeared fully within a month. lipomatous atrophy. In the Meibomian glands, Interestingly, after correction of the horizontal on September 27, 2021 by guest. Protected copyright. the mite Demodex brevis was present. laxity, the lash ptosis also disappeared. He has been free of symptoms now for 18 months (Fig 4). CASE 2 Histological sections of the excised upper An 84-year-old man (height 170 cm, weight eyelid block showed a moderate subconjunctival, 56 kg) was referred to our oculoplastic service chronic, inflammatory infiltration. In the tarsal because of a punctate epithelial keratitis of his plate a lipogranulomatous inflammation was right eye, attributed to an upper eyelid entro- present. Demodex brevis was demonstrated in the pion. He reported that he had been having discharge from the eye, and a gritty feeling, for more than 6 months. Symptoms were worse in the evening. He did not report eyelid eversion during the night. Elsewhere, his symptoms had been ascribed to a coexisting blepharitis. He had Figure 3 (A) Case 2 before surgery. (B) When the eyelid is pulled laterally, the severe laxity ofthe right upper eyelid is visible. Fig3A Fig 3B 668 van den Bosch, Lemrij Figure 4 Case 2, 2 months after excision ofafull Histological slides of the excised upper eyelid block showed a chronic thickness block from right subconjunctival follicu- Br J Ophthalmol: first published as 10.1136/bjo.78.9.666 on 1 September 1994. Downloaded from upper and lower eyelid. lar inflammation. In the tarsal plate, a severe lipomatous atrophy ofthe Meibomian glands was noted. There was a dense, chronic inflammation around the accessory lacrimal tissue. CASE 4 A 66-year-old, frail woman (height 156 cm, Meibomian glands. The dermis showed severe weight 39 kg) had undergone a cataract extrac- elastic degeneration. tion of the left eye elsewhere 18 months before she was referred to our hospital. A few days after the cataract extraction, she had developed a CASE 3 corneal ulcer. About the same time, a ptosis of An 83-year-old, moderately obese woman the left upper eyelid had come about. Treatment (height 165 cm, weight 82 kg) was referred to our with topical antibiotics had cured the corneal oculoplastic service because of punctate epithe- ulcer, although stromal loss of the lower part of lial keratitis ofthe right eye, thought to be due to the cornea had remained. Since the cataract a facial palsy. The facial palsy had been present extraction, she had been suffering almost perma- since an operation of the mastoid bone at the age nently from a purulent conjunctivitis, for which of 38. She had never undergone any surgery to she had been treated unsuccessfully with various improve eyelid apposition or function. For topical antibiotics. Finally, she was referred for several weeks she had suffered from strong evaluation of the chronic conjunctivitis. She irritation, discharge, and tearing from her right complained of chronic discharge and irritation eye. Her complaints did not vary during the day.