How a Drooping Eyelid Can Affect Your Sleep

A patient came to my office presenting with a drooping eyelid. He felt his eyelid was irritated when he slept. Sometimes he would wake up with discharge, irritation and a feeling of something in his eye.

On examination he had ptosis of the eyelid and the lashes were turning down. This “lash ptosis” was even seen on his good eye. When the eyelid was stretched it was loose, or floppy.

The patient has floppy eyelid syndrome, which is looseness of the eyelid. It was first described in 1981 at University of Miami by a corneal specialist, W Culbertson. Patients complain of trouble sleeping, eyelid irritation on waking, sleeping on the side of the worse eyelid and morning eyelid discharge. The irritation is commonly from the eyelid everting during sleep and becoming irritated against the bedsheets.

Floppy eyelid syndrome has a 96% association with sleep apnea. There are two primary hypotheses on how this relationship occurs. First, it is believed that patients with looseness of their airway have the same collagen makeup in their eyelids, resulting in abnormal flexibility of their eyelids. The second theory is that patients with sleep apnea sleep in a prone position and their eyelid is stretched over time as they are mechanically rubbing against sheets at night.

The classic triad of floppy eyelid syndrome includes ptosis, lash ptosis and eyelid laxity (Figures 1 and 2).

Floppy eyelid associated with sleep apnea can be related to other eye diseases including vein occlusions of the retina, optic nerve strokes (non-arteritic ischemic optic neuropathy), central serous chorioretinopathy and keratoconus. Vein occlusions of the retina and ischemic optic neuropathy are related to the vascular endothelial dysfunction that occurs with chronic sleep apnea. Central serous chorioretinopathy is associated with the sympathetic response from hypoxia at night in sleep apnea patients. Finally, keratoconus is abnormal bending of the cornea, which may share similar collagen dysfunction in patients with floppy eyelid syndrome.

Floppy eyelid is treated with tightening the eyelids, usually through incisions made on the lateral corner of the eyelids. By removing tissue there is a reduction in the looseness of the eyelid. However, the most important step for patients is testing and subsequent treatment of sleep apnea. Since sleep apnea is an independent risk factor for stroke, myocardial infarction and cancer, it is critical to have the patient tested before the eyelids are repaired. The concordance of sleep apnea and floppy eyelid syndrome is over 90%. Sleep apnea is commonly treated with CPAP but can also be managed with specially designed mouth guards and surgery. Patients may be asked to lose weight and reduce alcohol, both of which exacerbate the condition. Many patients say after starting CPAP they sleep “like they did when they were a kid”.

Floppy Eyelid Syndrome is a condition that is directly related to sleep apnea, a disorder with severe long-term sequelae. It is critical for physicians to identify this eyelid disease in order to screen for sleep apnea so patients can receive appropriate treatment and education.

Chris Thiagarajah MD FACS
Oculoplastic Surgeon 

A little about Chris: 
Chris Thiagarajah grew up in New Jersey and went to New York University for undergraduate. He then attended medical school and residency at Howard University in Washington D.C. He completed a neuro-ophthalmology fellowship at the University of Cincinnati and an ASOPRS approved oculoplastics fellowship in Denver at Park Avenue Oculoplastics. He practiced in Washington DC at Georgetown University before returning to Denver. He lives in Colorado with his wife Erin.