There was a recent article in the New England Journal of Medicine by Kara E. Shinder, et al, published on February 4, 2026 titled “Floppy Eyelid Syndrome.“
Abstract
A 39-year-old woman with obesity presented with a 6-week history of foreign-body sensation and tearing in both eyes. She reported daytime fatigue and snoring. Examination showed marked laxity of the upper eyelids.
Disease Entity
Floppy eyelid syndrome (FES) is an underdiagnosed, frequently bilateral eyelid malposition commonly involving the upper eyelids, presenting as recurrent or chronic ocular surface irritation and chronic papillary conjunctivitis of upper palpebral conjunctiva from severe eyelid laxity. It has a strong association with obesity, obstructive sleep apnea (OSA), etc.
Etiology
The extensive eyelid laxity can be attributed to significant decrease in elastin content when eyelid tissue was examined by special stains, immunohistochemistry, and electron microscopy. Mechanical stimulation of the lid results to the upregulation of enzymes causing elastolysis which degrades the elastic properties of the lid, resulting to tarsal laxity. Collagen content has not been noted to be decreased in these patients. This decrease in elastin content may explain the spontaneous eversion ("floppy") of upper eyelids especially at sleep, leading to chronic irritation and inflammation of the tarsal and palpebral conjunctiva being mechanically irritated by constant rubbing with the pillow. It has been observed that patients who sleep on one side more than the other side tend to have more severe changes on that side. This finding suggests mechanical injury as the primary cause of the papillary conjunctivitis in patients with FES. Other postulated pathophysiology suggests that the cause of the chronic conjunctivitis is poor apposition of the lax upper eyelid to the globe with inadequate spreading of the tear film.
Association
FES is known to be associated with obesity, male gender, obstructive sleep apnea, Down syndrome, and keratoconus. Keratoconus can also be linked to frequent rubbing and mechanical effect of upper eyelids on the cornea. Like a few other eyelid conditions related to upper or lower eyelid laxity, it is far less commonly seen in East Asians.
Diagnosis
History
Patients initially present with non-specific symptoms including eye irritation and a long history of unilateral or bilateral ocular redness and discharge. They may describe the eyelids spontaneously "flipping over" when they sleep, especially in prone position, due to rubbing on the pillow. Some patients may have a history of preexisting obstructive sleep apnea and/or history of heavy snoring. These symptoms in association with increased body mass index, or a diagnosis of obstructive sleep apnea and the ethnicity should alert the ophthalmologist about the possibility of floppy eyelid syndrome . However, many reports have also documented the symptoms and signs of floppy eyelid syndrome in patients of both genders and without a history of obesity or sleep disorders.
Physical Examination
Easy eversion of the eyelid without excess manipulation or even spontaneous eversion is an important examination mark for FES with subsequent increased horizontal laxity and redundancy of the lid. The lateral upper eyelid may appear elongated and imbricate (overlap) over the edge of the lower lid margin. Chronic severe papillary conjunctivitis with whitish mucus discharge is often present.
Diagnostic procedures
There is no diagnostic test for this entity. It is primarily a clinical diagnosis based on history, clinical features and systemic association. It should be directed to address possible associated conditions including obstructive sleep apnea and obesity. When possible, affected patients should be managed in cooperation with internal medical team and sleep disorder specialist.
Management
Supportive measures such as ocular lubrication, nighttime ophthalmic ointment and temporary antihistamine in addition to prevention of the upper lid from everting during sleep by taping the eyelids laterally or the use of eye shield can be effective in solving the patient's complaints temporarily. Addressing underlying obesity, obstructive sleep apnea and avoiding sleeping in the prone position may also improve symptoms. If there is minimal response to medical treatment, surgical procedures such as horizontal eyelid shortening with a lateral tarsal strip procedure can help to relieve ocular symptoms and provide good functional and cosmetic results. Surgery should be considered in significantly symptomatic patients.
General treatment
Obstructive sleep apnea is a potentially fatal disorder. Frequent episodes of apnea and hypopnea can lead to systemic and pulmonary hypertension and, ultimately, congestive cardiomyopathy and heart failure. Patients need to be managed by a sleep specialist to prevent these potentially fatal conditions.