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Karin Loeffler, Nina Stratmann, Teresa Maeueler, Frank Holz, Martina Herwig; Clinical and Histopathologic Characteristics in Floppy Eyelid Syndrome. Invest. Ophthalmol. Vis. Sci. 2013;54(15):3031.
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Floppy eyelid syndrome (FES) is a serious cause of therapy-resistent keratoconjunctivitis sicca. Nevertheless, it is a frequently overlooked entity. During the last 2 years, we have treated 8 patients successfully by upper eyelid wedge resection and have examined the excised tissue for specific histopathologic alterations.
Nine eyes from 8 patients were clincally diagnosed with typical floppy eyelid. Clinical data were collected, and all affected eyelids were - after exclusion of infectious or other causes and intensive treatment with artificial tears - treated surgically with upper eyelid wedge resection. - The eyelid wedge was submitted for ophthalmopathologic evaluation and embedded in paraffin. In addition to regular H&E and PAS stains, immunohistochemistry was performed using an antibody to collagen type V (CollV; BioLogo, 1:200 ), to macrophage marker CD68 (DAKO, 1:50) and to vimentin (DAKO, 1:500) and desmin (DAKO, 1:200). The immunoreaction product was visualized using AEC as chromogen. All sections were evaluated by 2 independent observers.
All patients were male with a mean age of 50 years at presentation (age range 39 to 69). Most were hypertensive, and in several patients sleep apnea was known. Symptoms had usually been present for some years, causing marked superficial keratitis despite intense lubrication. After surgery, all of our patients described almost immediate relief. With continuing use of lubricants, all but one patient were actually free of symptoms. - Histologic findings revealed tarsal atrophy (4/9), marked subepithelial inflammation (5/9), intraepithelial inflammation (2/9), epithelial metaplasia with elongated crypts and “buried” goblet cells (4/9), complete squamous metaplasia with no residual goblet cells (1/9) and eosinophilic infiltrates in a patient with atopic disease (2/9). Immunohistochemistry did not show significant distinctive findings when compared to normal controls.
Surgical intervention (upper eyelid wedge resection) was confirmed as a very rewarding therapeutical procedure. Histopathologic findings in floppy eyelid reveal some variation but loss of (exposed) goblet cells and inflammation are the most consistent findings. It remains unclear why FES is significantly associated with sleep apnea and why mostly male patients are affected.
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