Floppy Eyelid Syndrome

Floppy Eyelid Syndrome | Atlantic Eye | EyePlastics

Part of our complete guide to Blepharitis — this page covers floppy eyelid syndrome in depth.

What Is Floppy Eyelid Syndrome

Floppy eyelid syndrome (FES) is a condition in which the upper eyelids become abnormally soft, rubbery, and lax — so lax that they evert (turn inside-out) with only the gentlest pull, and often flip open on their own during sleep. The exposed inner lining of the eyelid rubs against the pillow night after night, producing a chronic, stubborn irritation of the eye that is frequently mistaken for ordinary conjunctivitis or dry eye.

Easy eversion of the upper eyelid with only minimal upward traction — the hallmark sign of floppy eyelid syndrome

Why it matters beyond the eye. Floppy eyelid syndrome is strongly associated with obstructive sleep apnea (OSA) and obesity. For many patients the eye findings are the first clue to undiagnosed sleep apnea — so recognizing FES can prompt a diagnosis that has major effects on overall health. Keratoconus is also more common in these patients.

Causes & Associations

The eyelid tarsus in FES shows a loss of elastin (linked to increased matrix metalloproteinase activity), leaving the lid floppy and easily deformed. Two mechanisms then drive the symptoms: spontaneous eyelid eversion during sleep, and repetitive mechanical rubbing of the everted lid against bedding.

Obstructive sleep apnea — present in a large proportion of patients; the single most important systemic association
Obesity and male sex (classically middle-aged men, though it occurs in women and slimmer patients too)
Side-sleeping — symptoms are often worse, or only present, on the side the patient sleeps on
Keratoconus and other corneal ectasias occur with increased frequency

Symptoms & Signs

Patients typically describe a red, irritated, watery eye that is worst on waking and never fully settles despite repeated drops. The signs at the slit lamp are characteristic once they are looked for.

Chronic redness, foreign-body sensation, and mucoid discharge — often one-sided
Easy eversion of the upper lid with minimal traction — the key diagnostic sign
A soft, rubbery upper tarsus and poor lid–globe congruity
Lash ptosis — the upper lashes point downward
Papillary conjunctivitis of the upper palpebral conjunctiva; punctate corneal staining
Frequently associated eyelid ptosis from stretching of the levator attachment

Close-up of the lax upper eyelid everting — soft rubbery tarsus — Close-up of the everted, lax upper eyelid — note the soft, rubbery tarsus

Lash ptosis — downward-pointing upper lashes

Floppy eyelid with associated upper-eyelid ptosis and lash ptosis

Diagnosis

FES is a clinical diagnosis that hinges on a high index of suspicion. Any patient with a chronic, one-sided, treatment-resistant red eye — especially an overweight, middle-aged man — should have the upper lid tested for easy eversion. Because of the strong link with sleep apnea, a key part of the work-up is screening for OSA and referral for a sleep study when indicated.

Treatment

Treatment has two goals: protect the eye at night, and address the underlying laxity and any systemic sleep apnea.

Conservative measures

Lubricating ointment at night and during the day to protect the ocular surface
A night shield, eye patch, or taping the lids closed to physically prevent eversion against the pillow
Treating obstructive sleep apnea (for example with CPAP) — often improves the eye symptoms and is important for the patient’s general health

Surgical correction

The series below shows the repair step by step — a pentagonal wedge of the lax lid is removed and the lid is tightened:

Marking the pentagonal wedge of upper eyelid to be removed — Step 1: the pentagonal wedge of lax eyelid to be removed is marked.

Wound closure shifting the upper eyelid nasally — Step 2: the wound is closed, shifting and tightening the eyelid.

The tightened upper eyelid after wedge closure — Step 3: the shortened, tightened lid immediately after closure.

Healed upper eyelid after wedge resection with a fine vertical seam — After surgery: healed lid with only a fine vertical seam.

When symptoms persist, the definitive treatment is horizontal eyelid tightening — a full-thickness eyelid-shortening or lateral tarsal-strip procedure that restores normal lid tension so the lid no longer everts. Associated ptosis or lash ptosis can be addressed at the same time. Results are generally durable, though recurrence can occur, particularly if associated obesity and untreated sleep apnea persist.

Pentagonal Wedge ResectionTightening the Lax Upper Eyelid

Drag the slider to step through the surgical correction.

Step 1 of 4

The pentagonal wedge of lax upper eyelid to be removed is marked

Wedge markedHealed

Drag the slider to step through the surgical correction (pentagonal wedge resection).

Floppy eyelid syndrome sits within the broader spectrum of eyelid laxity conditions, and the surgical tightening overlaps with techniques used for ectropion and entropion. Stretching of the eyelid can also cause ptosis.

Frequently Asked Questions

What is floppy eyelid syndrome?: Floppy eyelid syndrome is a condition in which the upper eyelids become very lax and rubbery and turn inside-out (evert) easily, often during sleep. The exposed inner lid rubs on the pillow and causes a chronic, one-sided red, irritated eye that is often mistaken for conjunctivitis.
Is floppy eyelid syndrome linked to sleep apnea?: Yes. Floppy eyelid syndrome is strongly associated with obstructive sleep apnea and obesity. In many patients the eye findings are the first sign of undiagnosed sleep apnea, so screening for it — and a sleep study when appropriate — is an important part of the evaluation.
How is floppy eyelid syndrome treated?: Initial treatment protects the eye at night with lubricating ointment and a shield or taping to stop the lid everting, along with treating any sleep apnea (for example with CPAP). When symptoms persist, the definitive treatment is a horizontal eyelid-tightening operation that restores normal lid tension.

Your Surgeon

Ronald W. Kristan, MD, FACS

Atlantic Eye

📞 (732) 222-7373