Eyelids and anterior segment : Case five

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This 48 year-old man was referred to the eye clinic because of a right sore eye especially in the morning. He was also under the physician for sleep apnoea syndrome. On examination, he had a right diffuse punctate keratitis and papillary conjunctivitis but otherwise the examination including visual acuity was normal.

a. What relevant history would you like to elicit?

The side that the patient sleeps on is relevant.

b. What is shown in the above picture?

The picture shows that the right upper lid is loose and can be pulled forward a long way.

c. What is the most likely diagnosis?

Floppy eyelid syndrome.

The upper lids are lax and easily everted allowing the conjunctiva and cornea to come into contact with the pillow. The symptoms are typically worse in the morning with redness and mucous discharge. The main ocular signs are punctate keratopathy and papillary conjunctivitis. The aetiology of the lax upper lid is unknown. Most sufferers are obese and suffer with sleep apnoea syndrome.

d. How would you manage this condition?

Treatment is aimed at preventing the eversion of the upper lid and this can be achieved with either:

• tapping of the upper lid at night                 or
• horizontal lid shortening to tighten the lid