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 HAVE AN INTERESTING CLINICAL CASE? Email the editor at [email protected]. We pay $400 for each case and photos are encouraged. 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 ONLINE MODULE ● TAILORING TREATMENT FOR VTE Take a closer look at VTE management in general practice by delving deeper into the preventable and treatable nature of this condition. Learn more about specific risk factors that influence treatment decisions, as well as appropriate non-pharmacological and pharmacological management strategies for specific patient groups. This module includes expert video commentary and practical case studies provided by Prof Christopher Ward, clinical haematologist at Royal North Shore Hospital, Sydney. Complete this CPD accredited on-line module FREE OF CHARGE AND IN YOUR OWN TIME. www.australiandoctor.com.au/education 2 16 | Australian Doctor | 27 October 2017 This education is independently created by Australian Doctor Education and sponsored by www.australiandoctor.com.au