Chronic SPK and Recurrent Corneal Abrasions…Diagnosis? Floppy Eyelid Syndrome

A 48-year-old male was referred to the clinic with chronic photophobia, redness and pain.  His best-corrected vision was 20/40 OD and 20/200 OS!  His cornea showed grade 3+ staining OS >OD, he had grade 3+ injection and chemosis, but there was no discharge and the anterior chamber was deep and quiet.  Fundus examination had always been unremarkable and without pathology.

Previous doctors had tried artificial tears, corticosteroids, cyclosporine, allergy medications, oral doxycycline, antibiotic ointments and combination antibiotic/steroid drops, but all to no avail.  He was treated with hypertonic drops and ointment for recurrent erosion, which had limited success as well.  Corticosteroid drops worked the best at improving the signs and symptoms but without complete resolution. As he tapered the medications a rebound would occur and eventually the symptoms persisted even in the presence of corticosteroid drops.  Antibiotic ointments also helped but could not fully improve his condition.  The patient had been suffering on and off with this for almost three years!

The Diagnosis?

In cases of chronic SPK consider Floppy Eyelid Syndrome. The lack of a tight eyelid results in chronic inflammation to the cornea and conjunctiva as was evident by the corneal and conjunctival edema and staining.  Lifting his upper eyelids showed them to be extremely “elastic,” and they could be flipped with one finger or even pulled approximately two inches away! This condition is more common in overweight, middle-aged males as was the case here[1].  The patient also confirmed a history of sleep apnea, which is also consistent with FES[2].  The only option for FES this severe is surgical repair, which the patient underwent two weeks ago and is already showing significant improvement to signs and symptoms.  We continue to maintain the best possible ocular surface with artificial tears, punctal plugs and therapeutics for the chronic SPK associated with this condition, but it has greatly improved after surgical intervention.

[1] Pham TT, Perry JD. Floppy eyelid syndrome. Curr Opin Ophthalmol. 2007;18(5):430-3.

[2] Karger RA, White WA, Park WC, et al. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Ophthalmology. 2006;113(9):1669-74

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