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By: Brendan Duffy on April 11th, 2016

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Floppy Eyelid Syndrome (FES): Why Optometrists See Sleep as an Issue

Sleep Disorders


Brendan Duffy shares how optometrists are increasingly aware of the partnership between sleep and eye health 

Duffy_Brendan_Headshot.jpgI have been working in the sleep medicine field for almost 20 years, but it wasn’t until the last few months that I saw a patient referred to our sleep center from an Optometrist! He has referred a few patients in the past year and that piqued my interest as to what the eye doctor “saw”. Those referrals started my quest to learn about his symptom listing of FES - Floppy Eyelid Syndrome!

The Floppy Eyelid Syndrome and sleep apnea connection, according to Brad Sutton OD, FAAO of Indiana School of Optometry is “essentially 100%” according to an online article at the website www.healio.com.  

In FES, the eyelids become loose and rubbery. They can evert, i.e. turn inside out, with very little pressure. It appears that this condition worsens as the eyelid flaps while the patient is sleeping. FES is associated with chronic eye irritation and burning, tearing, a mucous discharge (usually in the morning) decreased vision, conjunctivitis, dry eye, and daytime somnolence and morning headaches. FES is also associated with keratoconus which is a condition in which the clear tissue on the front of the cornea bulges outward. Past history may also include contact lens use as well as seasonal allergy, psoriasis, hypertension, CHF, and previously diagnosed OSA.

Dr. Sutton stressed how important it is that the medical intake forms and review of systems used by optometrists includes questions about sleep apnea symptoms, as patients won’t make the connection between their sleep and their eye problems. He mentioned this diagnosis connection is often missed by practitioners and these patients tend to arrive with several bottles of eye drops that are not helping them.

FES is confirmed by having the patient look down while you pull the eyebrows up. When you do this, the FES patients upper eyelids will evert.  Another clue to a positive FES diagnosis is eyelashes that point downward.

A study in the Journal of Sleep Medicine in 2012 conducted at the Strasbourg University Sleep Clinic in France found a significant correlation between OSA severity and FES. This seems to suggest that severe OSA may be a risk factor for FES. The two disorders seem to play upon the same determinants, such as tissue elasticity.

As for treatment of Floppy Eyelid Syndrome…….

Dr Sutton urges his patients to get tested for sleep apnea.

He also has a three part program for improvement of FES:

-use a thick lubricating ointment at night

-sleep with a syndical pillow to prevent contact with the eye to the pillow which prevents further irritation and furling of the eyelid, and

-wear a firm eye mask to prevent lid eversion.

Ultimately FES may require a surgery to retighten the area in question.

So yet we have another possible clue, or marker, compliments of our friends in the Optometry world, to assist us to diagnose and treat Obstructive Sleep Apnea.

Hopefully, with the eyes healed and the patient getting a good night’s rest, the only eyelid moments will be REM and not FES!

About the author Brendan Duffy

Brendan has worked in sleep technology for the past 18 years and has been a regular member of the AASt for the past 16 years. Brendan has been on the AAST membership committee for the past few years, has contributed regularly to the AAST blog since its founding in 2015. While interested in all facets of sleep medicine , Brendan has a special interest in sleep medicine  in connection with sports medicine and has written several articles,-  and  given presentations,  about how sleep  impacts athletic performance, training, and recovery.

To read more of Brendan's work click here

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