19.1 Goals

Floppy eyelid syndrome (FES) consists of excessively elastic and rubbery upper eyelids that are easily everted with minimal effort (Fig. 19‑1a). The condition is often asymmetric and the worse side corresponds to the side the patient most often sleeps on. Presumably, nocturnal eversion of the eyelid allows for exposed palpebral conjunctiva and mechanical trauma. This results in a chronic papillary conjunctivitis (Fig. 19‑1b). ¹ Associated ocular findings can also include punctate epitheliopathy, keratoconus, dermatochalasis, blepharoptosis, eyelash ptosis, and blepharitis. ¹

The goal of surgery is to improve patient symptoms through limitation of nocturnal exposure and mechanical irritation. This can be achieved primarily through an upper and lower eyelid lateral tarsal strip (LTS) procedure. While initially described as a lower eyelid procedure, the LTS can also be used in the upper eyelid with excellent results. Associated periocular morbidities such as eyelash ptosis, blepharoptosis, dermatochalasis, upper eyelid entropion, or lower eyelid ectropion can be addressed concurrently.

19.2 Advantages

There are various surgical techniques described to treat FES. These include pentagonal full-thickness wedge resection (FTWR), upper eyelid medial canthal/lateral canthal tendon plication, and upper eyelid medial canthal strip. The upper eyelid LTS procedure offers the advantage of preservation of eyelid structures, namely the central tarsal plate that contributes to the structural integrity of the eyelid. Higher recurrence of FES is seen with FTWR alone. To achieve adequate tightness of the eyelid, FTWR necessitates resection of a large percentage of tarsal plate. Histopathologic studies reveal a decrease in tarsal stromal elastin fibers and increased matrix metalloproteinase activity. ² Aggressive resection and manipulation of the attenuated tarsus may further degrade the abnormal tarsal plate and predispose a patient to recurrence of FES. ³

The upper and lower LTS procedure produces an aesthetic scar within the horizontal relaxed skin tension lines of the eyelid and lateral canthus. The classic pentagonal FTWR creates incisions perpendicular to the relaxed skin tension lines of the eyelid and has the potential for noticeable scarring. Variations on the classic pentagonal FTWR have been described to enhance cosmesis of scars. ⁴

In contrast to plication of the medial canthal or lateral canthal tendons, the LTS serves to create a new scar plane between the fashioned tarsal strip and the lateral orbital rim. The created tarsal strip is wider than the tendon and is fixated to the lateral orbital rim at two points with a double-armed suture. This forms a broad-based scar plane that may better anchor the lid laterally, thus limiting rotation around this axis and spontaneous eversion of the eyelid. ³

19.3 Expectations

The expectation of the upper and lower LTS procedure is to reduce horizontal eyelid laxity and to create a broader pivot point at the lateral canthus, thereby limiting spontaneous eyelid eversion. In the upper eyelid, this is accompanied by resection of the upper limb of the lateral canthal tendon which is approximately 10 mm in length. This achieves horizontal tightening and maximal preservation of the tarsus.

19.4 Key Principles

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  In general, patients with FES benefit from LTS procedure on both upper and lower eyelids.

  
  
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  Maximal resection of the lateral canthal tendon should precede any tarsal shortening, though some lateral tarsal shortening may be necessary to optimize eyelid tone.

  
  
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  Permanent suture should be used to fixate the tarsal strip to the periosteum of the inner orbital rim at Whitnall tubercle.

  
  
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  Optimal fixation can be achieved by using the horizontal mattress technique. A double armed suture can facilitate this.

  
  
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  Upper and lower LTS can be combined with other procedures to address associated periocular morbidities.

19.5 Indications

Surgeons must maintain a high index of suspicion for FES. While initially described in obese, middle-aged males, ⁵ it can also affect women, non-obese patients, and even children. ^{1 ,​ 6} Patients typically present with chronic ocular irritation, redness, and mucous discharge. ¹ FES has systemic associations, most notably obstructive sleep apnea (OSA) and all patients must undergo a sleep study. ^{1 ,​ 7} Patients diagnosed with OSA are often treated with nocturnal positive airway pressure machines that can exacerbate mechanical eyelid irritation and exposure keratoconjunctivitis through airflow leakage. Nonsurgical measures may initially be tried, including refitting of the positive airway pressure mask, nighttime eyelid taping and patching, eyelid hygiene, ocular surface lubrication, ocular steroids, and punctal plugs. ^{1 ,​ 8} When conservative measures fail, surgical intervention is indicated.