1

Introduction

Floppy Eyelid Syndrome (FES) is an eyelid disorder first described in 1981 by Culbertson and Ostler . It is characterized by very loose upper eyelids that easily evert with minimal upward and lateral traction of the upper eyelids. The lower eyelids are typically affected as part of FES as well. The upper eyelids evert during sleep and cause a mechanical irritation to the palpebral conjunctiva and exposure of the eye, leading to significant papillary conjunctivitis and exposure keratopathy. Patients are classically middle-aged, overweight men, and there is a significant increased association with obstructive sleep apnea. Patients have predominately unilateral disease, and the laterality usually corresponds to the side that the patient prefers to sleep on. Other ocular findings include: keratoconus, dermatochalasis, blepharoptosis, eyelash ptosis, blepharitis, epiphora, lower eyelid laxity and/or ectropion ( Fig. 1 ) .

Clinical photos of patient with bilateral Floppy eyelid syndrome. The upper eyelids easily evert with minimal upward and lateral traction (top). The lower eyelids exhibit severe laxity (bottom). The eyelids can easily evert during sleep and lead to severe corneal exposure and conjunctivitis.

The underlying pathogenesis of FES is not fully understood. It has been observed that many FES patients also frequently rub their eyes, suggesting a mechanical etiology for the progressive laxity of the eyelids. Several studies analyzing the histopathology of eyelids in FES have demonstrated reduction in the quantity of elastic fibers within the tarsus . Clinically the authors have noted that a large majority of the laxity comes from stretching of the medial and lateral canthal tendons as opposed to the tarsus.

Conservative medical treatment consists of ocular lubrication, wearing an eye shield during sleep, and weight loss. Diagnosis and treatment of underlying obstructive sleep apnea are also important, as there are reports of FES resolving with the use of a continuous positive airway pressure mask . The association of FES and OSA was first suggested by Woog in 1990, and McNab subsequently found 26 of 27 of his patients with FES to also suffer from OSA .

Various surgical techniques have been described, focusing on horizontal tightening to improve the eyelid laxity with varying degrees of success. The authors describe their experience with medial canthopexy combined with lateral tarsal strip to correct the laxity of the upper eyelid without sacrificing upper eyelid tarsus or affecting the position of the puncta.

2

Patients and methods

We retrospectively analyzed the medical charts of 16 patients over a 4-year period in whom medial canthopexy was used to augment surgical management of floppy eyelid syndrome (FES). Preoperative factors assessed in this study included: patient age, gender, laterality, and presence of obstructive sleep apnea, papillary conjunctivitis, punctate keratopathy and lash ptosis. Outcomes assessed in this study include improvement in eyelid laxity, operative complications, post-operative symptomatic relief and delayed recurrence of FES.

2.1

Operative technique

Corneal protectors are placed in both eyes and the upper and lower eyelids on the operative side are infiltrated with local anesthetic. A surgical marking pen is used to mark a medial canthal incision and two incisions just lateral to the punctae and approximately 3 mm from the eyelid margin ( Fig. 2 , top-left). A 15 Bard Parker blade is use to make an incision in the medial canthus just anterior to the canthal tendon, exposing the anterior portion of the tendon ( Fig. 2 , top-right). Next, small (5 mm) snip incisions are made using Wescott scissors just lateral to the puncta and 3 mm from eyelid margin on the upper and lower eyelids to expose the medial border of each tarsus ( Fig. 2 , middle-left). A 6-0 polygalactin suture is then used in a horizontal mattress fashion to ligate the medial borders of the upper and lower eyelid tarsus to the medial canthal tendon. The 6-0 polygalactin suture is first passed through the medial border of tarsus ( Fig. 2 , middle-right), and then passed under the skin to the medial canthus incision ( Fig. 2 , bottom-left). The suture is then secured to the medial canthal tendon and passed back under the skin to the subciliary incision. The mattress suture is then tied to the desired tightness ( Fig. 2 , bottom-left).

Intraoperative photos of medial canthopexy.

Next, horizontal shortening of the upper and lower eyelids is achieved laterally by performing a lateral tarsal strip. A 15 blade is used to perform lateral canthotomy and straight scissors to perform lateral cantholysis. Both the upper and lower limbs of the canthal tendon are then released, and a full-thickness segment of the lateral tarsus (2–5 mm) is excised. The appropriate amount of shortening was determined based on the degree of lid laxity in the standard fashion for the lateral tarsal strip. The lateral tarsus of the upper and lower eyelid is then re-approximated to the lateral orbital rim periosteum using 5-0 polygalactin suture. A small amount of excess skin is excised from the upper eyelid and the skin incisions are closed using interrupted 5-0 fast-absorbing gut suture.

If the patient has bilateral FES, we prefer to perform upper and lower eyelid tightening on one side as an initial procedure, followed by the contralateral side in 3–6 weeks.