Floppy Eyelid Syndrome

What is floppy eyelid syndrome?

Floppy eyelid syndrome is a condition that happens when the skin of your eyelids becomes loose and rubbery. This may cause the eyelid to fold and turn inside out more easily, especially while you’re asleep. It can affect both upper eyelids at the same time.

How common is floppy eyelid syndrome?

Research shows floppy eyelid syndrome affects between 2% and 4% of people worldwide. But experts suspect that the true number is much larger. Floppy eyelid syndrome’s symptoms can happen entirely on their own or with many other conditions. Researchers suspect healthcare providers and eye care specialists commonly treat the symptoms without realizing they’re part of this syndrome.

What are the symptoms of floppy eyelid syndrome?

Floppy eyelid syndrome has several possible symptoms, and they’re often worse right after you wake up. The symptoms include:

• Eyelids that are very loose and stretchy, or that turn inside out with very little effort.
• Eye pain or a burning sensation.
• Dry eyes (because your tear fluid doesn’t lubricate your eyes correctly).
• Watery eyes (because your body tries to maintain eye moisture by producing more tear fluid).
• Eyelid soreness or swelling (blepharitis).
• Feeling like something is stuck in your eye.
• Light sensitivity (photophobia).
• Mucus discharge from your eyes.

Why floppy eyelid syndrome is an issue

Your eyelids are the thinnest area of skin on your body. To work properly, they need to be elastic (stretchy). That’s how they can have enough tension to lay flat against your eyeball but still have enough “give” to move up and down when you open, close or blink your eyes.

But your eyelids are more than just a covering. They also contain the meibomian glands, which release an oily substance called meibum (pronounced “MAY-bum”). This substance is key to how your tear system works. Meibum mixes into your tear fluid, lubricating the surface of your eyes and slowing the evaporation of tear fluid. It also helps your eyelids seal and become airtight when your eyes are closed, which keeps moisture in.

When your eyelids lose elasticity, they sag and don’t remain in place. That means meibum from these glands can‘t mix into your tear fluid correctly, disrupting your eyes‘ lubrication. It also means your eyelids can shift and move too easily and may not have an airtight seal when shut (which can happen frequently while you‘re asleep).

What causes floppy eyelid syndrome?

Floppy eyelid syndrome happens when you lose elastin in your eyelids. Experts don’t fully understand why that happens, but research implicates a few suspects. It’s unknown if these are causes or just contributing factors, but experts suspect they play a role:

• Obesity and obstructive sleep apnea (OSA). These two conditions are closely linked, and your risk of having OSA increases if you have obesity or overweight. OSA keeps you from breathing while you’re asleep. The resulting lack of oxygen affects chemical reactions in your body, increasing the presence of enzymes that can break down elastin. About half of people with OSA also develop floppy eyelid syndrome.
• Connective tissue disorders. These are conditions that affect connective tissues like cartilage, tendons and more. These conditions can also affect the way your body makes and uses elastin. Examples of these disorders include Marfan syndrome and Ehlers-Danlos syndrome.
• Genetics. DNA mutations can affect the way your body makes and uses elastin. These can be mutations you inherited from a biological parent or that you developed spontaneously while you were a developing fetus.
• Other conditions that affect your eyes and surrounding tissue. People with conditions that cause bulging eyes or similar effects may have a higher risk. Examples include thyroid diseases, like Hashimoto’s disease, and other conditions that can cause bulging eyes.

Other contributing factors to this condition include:

• Sex. People assigned male at birth (AMAB) are more likely to have floppy eyelid syndrome. About two-thirds of cases affect AMAB individuals.
• Age. This condition is much more likely in adults. Children can have it, but that’s rare.
• Race. People with an epicanthic fold (especially people of Asian descent) may be less likely to have this condition because of the structure of their eyelids.

What are the complications of floppy eyelid syndrome?

Floppy eyelid syndrome affects your eyes‘ self-lubrication and moisture. When those don‘t work right, your eye is prone to irritation and damage. Examples of conditions that happen like this include:

• Dry eye disease.
• Corneal inflammation (keratitis).
• Recurrent corneal erosion (RCE).
• Corneal ulcers and scarring.
• Vision loss (in severe or untreated cases).

How is floppy eyelid syndrome diagnosed?

The symptoms of floppy eyelid syndrome happen with many conditions, and there aren’t any tests for this condition.

An eye care specialist can diagnose this condition based on the symptoms you describe, by asking questions about your vision and how your eyes feel, and by examining your eyelids. During that examination, they‘ll place their fingertip against the skin of your eyelid. The touch will be light enough that it won‘t hurt but firm enough to see how far your eyelid can move and stretch.

Many eye specialists also use this method to determine how severe floppy eyelid syndrome is, if you have it. There are two severity grading systems that providers might use:

• Measurement system: This uses measurements of lid movement. This scale’s range is 0 to 4.
• Conjunctiva visibility system: This has you look downward while your eye specialist holds your eyelid upward. The visibility of the upper conjunctiva (the white area above your iris and pupil at the front of your eye) determines the severity grade. This scale’s range is 0 to 3.

How is floppy eyelid syndrome treated?

There are two main approaches to treating floppy eyelid syndrome: conservative and surgical.

Conservative approach

The conservative approach focuses on preventing the symptoms of this condition. It usually involves sleeping with your eyes taped shut, wearing an eye shield to sleep, or putting in artificial tears or ointment at bedtime. Your provider will also recommend a sleep study to check if you have OSA (you can have OSA even if you don’t have obesity or overweight).

If you have OSA, using a continuous positive airway pressure (CPAP) or bilevel positive airway pressure (often known as BPAP or under the trademarked name BiPAP®) machine can reverse the loss of elastin and improve eyelid elasticity. Using it every night is important, or it’s less likely to help. (And untreated OSA can be deadly, which makes using your machine even more important.)

Surgical approach

The surgical approach is usually the backup option if the conservative approach isn‘t helpful. It‘s also an option if you have severe floppy eyelid syndrome and there’s a risk of eye damage. Several surgical procedures can tighten your eyelid tissue, making it less floppy. Your eye specialist or surgeon will tell you more about the procedure they recommend and what you should expect.

Can floppy eyelid syndrome be prevented?

Experts don’t yet know exactly how floppy eyelid syndrome develops, so it isn’t preventable. But they think you can reduce your risk of developing floppy eyelid syndrome by treating or preventing conditions that may contribute to it. That can include any or all of the following:

• Reaching and maintaining a weight that’s healthy for you.
• Using your positive airway pressure machine as recommended every night without exception.
• Managing any chronic conditions you have (like Hashimoto’s disease) to prevent eye-related changes that could contribute to floppy eyelid syndrome.

What can I expect if I have floppy eyelid syndrome?

If you have floppy eyelid syndrome, you’ll likely experience symptoms that revolve around problems with eye moisture. The symptoms are usually at their worst in the morning when you wake up. If you prefer to sleep on your side, the eye on the side you prefer to sleep on will usually have more severe symptoms. This condition isn’t dangerous directly, but it can lead to permanent eye damage and affect your vision.

If you suspect you have floppy eyelid syndrome, it‘s a good idea to see an eye specialist so they can check. If you do, they‘ll also recommend seeing a provider to check you for OSA and treat you if necessary.

The only way for floppy eyelid syndrome to go away on its own is if you resolve whatever’s causing it, such as OSA. But you should always get OSA treated because it can have life-threatening complications.

What’s the outlook for floppy eyelid syndrome?

The outlook for floppy eyelid syndrome is very good when treated. Using OSA treatments like CPAP or BPAP will likely improve your symptoms at least partly. The remaining symptoms should be less severe and easier to manage with other conservative treatments.

Surgery also has a very high success rate for resolving floppy eyelid syndrome. The success rate for surgery is between 91% and 98%.

How do I take care of myself if I have floppy eyelid syndrome?

If you have floppy eyelid syndrome, following your eye care specialist‘s guidance as closely as possible is important. Protecting your eyes while you sleep needs to be a priority. You should also use artificial tears, ointments or other products as recommended. It’s also very important not to rub your eyes. This can make your eyelid less elastic.

If your provider refers you to a sleep specialist to check for OSA, you should do that as recommended. If diagnosed, you should also follow your sleep specialist’s guidance closely. That’s essential because untreated OSA can be deadly.

When should I see my healthcare provider or when should I seek care?

Untreated floppy eyelid syndrome can lead to permanent eye damage. If you have symptoms of it, you should see an eye specialist sooner rather than later. It’s not an emergency condition, but it’s also not one you should try to tolerate, ignore or self-treat.

And if you already know you have it, you should talk to your provider if your symptoms change or get worse. You can also talk to them if treatments aren‘t helping or becoming less effective.

What questions should I ask my doctor?

Some questions you can ask your provider include:

• How severe is my floppy eyelid syndrome?
• How is it affecting my eye now?
• What can I do to treat my condition right now?
• What are complications or side effects I should know about and watch for?

What’s the difference between floppy eyelid syndrome and other conditions that cause eyelid droop?

There are two other ways eyelid droop (ptosis) can happen. They include:

• If the muscles in your eyelid are weaker because of an issue with the muscles themselves.
• If the nerves that connect to the muscles aren’t working correctly, disrupting the signals that make the muscles move.

Floppy eyelid syndrome is different from those other two ways because it involves skin elasticity specifically. It doesn’t involve or affect the muscles or nerves related to eyelid movement.

A note from Cleveland Clinic

Floppy eyelid syndrome may seem minor, but it‘s likely a sign of obstructive sleep apnea, a more severe — and even deadly — condition. And without treatment, floppy eyelid syndrome can cause permanent eye damage, too.

If you have the symptoms of floppy eyelid syndrome, you shouldn’t ignore them or try to tough it out. Getting this condition diagnosed and treated can help you feel and see better, and possibly avoid dangerous complications.