Australian Doctor Australian Doctor 27th October 2017 | Page 16
Grand Rounds
In plain sight
THE AUTHOR
OPTHALMOLOGY
Chronic eye irritation can mimic other symptoms, but is
often associated with a serious sleep disorder.
Dr James Slattery is an
ophthalmologist and
oculoplastic surgeon
who practises in
Adelaide, SA.
M
ATTHEW, an obese 38-year-old man,
presents with an enlarging right upper
eyelid mass associated with copious
mucoid ocular discharge. It is particu-
larly severe in the morning. He works night shifts, is
a heavy smoker and has a BMI of 39.
He has a background of poorly controlled hyper-
tension despite compliance with a calcium channel
blocker and ACE inhibitor. Systemic workup has
failed to identify a secondary cause for his hyperten-
sion.
He has seen his GP on multiple occasions with
conjunctivitis and ocular discharge associated with
burning, itchiness and grittiness affecting his right eye
more than the left. It has not responded to topical
antibiotics.
He has noticed a slow-growing lesion under his
right eyelid (figures 1), causing aesthetic concerns,
and is subsequently referred for ophthalmic specialist
opinion.
Further history reveals an Epworth sleepiness score
of 22/24, which he attributes to working at night. He
consistently sleeps on his right side and, according to
his partner, is a heavy snorer.
Examination
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Ocular examination revealed Matthew had an
unaided visual acuity of right eye 6/9, left eye 6/6. He
had giant papillary conjunctivitis of his right upper
tarsal conjunctiva causing a mechanical upper lid
ectropion. Hyper-laxity of the upper lid was noted
with easy eversion.
He had bilateral, right greater than left lash pto-
sis, with right greater than left upper and lower lid
dermatochalasis, and excess wrinkling of periocular
skin.
Corneal examination revealed diffuse punctate epi-
thelial erosion.
Diagnosis
This case highlights the typical history and clinical
features of floppy eyelid syndrome (FES).
Matthew was referred for a sleep study and was
found to have severe obstructive sleep apnoea
(OSA). He was advised to lose weight and started
on continuous positive airway pressure (CPAP) via
a mask at night. He was prescribed ocular lubri-
cants, a steroid ointment and lid shield at night,
but this treatment failed because of his discomfort
with the mask.
He subsequently underwent upper and lower lid
tightening.
Discussion
FES is a well-described but underdiagnosed entity
with characteristic features.
Patients typically present with chronic irrita-
tion, redness and copious morning mucous dis-
charge. These non-specific symptoms may mimic
other common conditions such as blepharitis or
dry eye syndrome, meaning the diagnosis is often
delayed or missed, and a high index of suspicion
is required.
The tarsus is lax and malleable in contrast to
the normal rigid tarsus, resulting in the hallmark
clinical feature of an easily everted upper lid. The
eyelid may also demonstrate abnormal thickness,
a rubbery consistency, an excess of wrinkled peri-
ocular skin and eyelash ptosis — particularly tem-
porally. Eyelid laxity may be present in the lower
lid, which might be ectropic.
Corneal sequale, most commonly punctate
corneal epitheliopathy, is common given the lid
changes are often combined with tear dysfunction.
Importantly, FES occurs in association with
multiple ophthalmic and systemic conditions,
most notably OSA. Although poorly understood,
Figure 1. Slow-growing lesion.
the relationship has diagnostic and therapeutic
implications because FES may be a presenting fea-
ture of patients with undiagnosed OSA.
The incidence of FES in OSA patients varies
markedly in the literature but most patients with
FES also have symptoms of OSA.
Patients with FES and OSA also tend to be
younger and have more severe OSA.
FES may present at any age and with any body
habitus but is most commonly seen in overweight,
middle-aged males.
The underlying pathophysiology of FES appears
to be related to a loss of elastin fibres in the stroma
of the tarsal plate, resulting in significant tarsal
laxity. Similar changes are found in the eyelid,
which explains the lash ptosis and blepharoptosis
in these patients.
Keratoconjunctivitis is thought to be associ-
ated with mechanical eversion of the eyelid during
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