Horizontal tightening of upper eyelid helps with floppy eyelid syndrome

Key Points

Las Vegas-In a study of patients with floppy eyelid syndrome (FES) by David Mills, MD, Andrew Harrison, MD, and Dale R. Meyer, MD, FACS, upper eyelid tightening generally resulted in secondary, quantifiable elevation of upper eyelid position and improvement in the relative ptosis in approximately 92%. Eyelash ptosis was also qualitatively improved.

"Based on the results of our study, we feel that unless the associated upper eyelid ptosis is particularly severe, it appears reasonable to perform surgical correction of FES with horizontal tightening alone as the initial treatment strategy," said Dr. Meyer, who presented results from the study at the American Academy of Ophthalmology annual meeting during a session on orbital, lacrimal, and plastic surgery.

"Secondary surgery for ptosis correction could be performed with standard techniques if indicated or requested. In this study, however, all patients were pleased with the eyelid correction and no patient requested an additional ptosis correction," continued Dr. Meyer, professor of ophthalmology at Albany Medical College, Albany, NY.

Classic case

The classic FES patient is an overweight, middle-aged male, although the syndrome occasionally may be encountered in women and non-obese individuals. Many of these patients also suffer from obstructive sleep apnea.

According to Dr. Meyer, the simplest form of treatment consists of topical lubricating or antibiotic ointments and eyelid shielding to prevent nocturnal eyelid eversion. Surgical treatment typically involves horizontal tightening of the lateral upper eyelid by full-thickness wedge resection or tarsal strip procedure. Other surgical procedures such as lateral tarsorrhaphy, anterior lamellar repositioning, or medial canthal tightening also have been described.

An association between upper eyelid ptosis and FES also has been reported. Because of this association, some surgeons combine repair of the two conditions, Dr. Meyer said.

Most studies of FES treatment have focused on improvement of the ocular surface or corneal changes. However, little information is available in the peer-reviewed literature regarding the change in eyelid position with horizontal tightening alone. Therefore, Dr. Meyer and his colleagues performed a study to examine the change in eyelid positioning following full-thickness wedge resection for FES.

In this case series, horizontal surgical tightening of the affected upper eyelid was performed in 24 eyelids of 18 patients; 13 cases involved the upper right lid and 11 the upper left. One surgeon performed all procedures at two clinical centers.

Surgical treatment consisted of a resection performed at the junction between the lateral third and the medial third of the eyelid using a standard full-thickness pentagonal wedge incision, adjusting the amount of resection on the table for the amount of laxity present.

Preoperative and postoperative upper eyelid position margin reflex distance (MRD) was measured. Patients were seen postoperatively at 1 week and 3 months. Patients who were referred by general ophthalmologists and whose conditions were stable were returned to their care at 3 months. Those without referring ophthalmologists were scheduled for additional follow-up at 6 months and 1 year.

The mean age of the patients at the time of surgery was 56 years (range, 38 to 76), and all but one of the patients were male.

The mean preoperative MRD was 1.9 mm (±1.3 mm SD), and the mean postoperative MRD was 3.2 mm (±1.4 mm SD). The mean postoperative change in MRD was an increase of 1.3 mm (±0.7 mm SD, p < 0.001), which was highly statistically significant, Dr. Meyer said. The postoperative measurements were obtained from 3 to 12 months, with a mean of 4.6 months.

The postoperative change in MRD ranged from a decrease of –0.05 mm in one patient to an increase of 2.5 mm in another. Upper eyelid position improved in 22 of 24 lids, was unchanged in one, and was slightly worse in another.