Infectious-Like Corneal Epitheliopathy Caused By Floppy Eyelid Syndrome

Floppy Eyelid Syndrome (FES) is an entity characterized by upper eyelid hyperlaxity, allowing the eyelid to evert easily. At the level of the cornea and ocular surface, FES is associated with a variety of symptoms including tearing, ocular redness, foreign body sensation, mucous secretions, dryness and superficial punctate keratitis.  In most severe cases, it can lead to corneal ulcers and loss of visual acuity. The aim of this case report is to emphasize the importance of exploring eyelids when we find an alteration on the ocular surface.

Department of Cornea and Ocular Surface, Barraquer Eye Center, Barcelona, Spain

A 64-year-old male patient who came in with loss of vision in the left eye for 3 years. He had been visited by different ophthalmologists with the diagnosis of herpetic epithelial keratitis. He has currently been treated with acyclovir 200 mg orally per day and artificial tears on demand. On examination, best corrected visual acuity (BCVA) was 0.15 in the left eye. Upon asking patient's history, this revealed the use of myopic contact lens hence, acanthamoeba keratitis was suspected. Epithelial PCR for HSV and acanthamoeba was carried out with negative results for both. After epithiliectomy, hazy corneal epithelium grew over almost the entire cornea with a demarcation line separating normal from abnormal epithelium leading to CIN suspicion.

Total epithelial biopsy was carried out. The result of the biopsy revealed stratified flat epithelium with no cellular atypia nor mitosis, thus ruling out CIN. Patient’s habits were asked thoroughly when it was revealed that he used to snore and has been sleeping in a left lateral decubitus position with face down on the pillow all his life. Therapeutic contact lens was placed over the cornea and an eye shield was given to protect his left eye at bedtime. 50% autologous serum every hour and dexamethasone eye drop 3 times a day were prescribed.  On one month follow-up, the patient refers improvement in his vision and has no eye discomfort. On examination, BVCA in his left eye was 1.2 and the corneal epithelium was entirely normal.

The role of the eyelids in maintaining the homeostasis of the ocular surface is of great importance. For this reason, we should not overlook their examination in consultation when there is an alteration of the corneal epithelium that does not improve with targeted treatment, especially in cases of palpebral malposition, incomplete palpebral closure, or marked hyperlaxity, as in our case. If a palpebral alteration is found, it is important to carry out a directed anamnesis. In our case, if FES is suspected, ask about sleep habits (quantity, quality), whether the patient snores, how long it has been going on and whether he or she sleeps on his or her side.