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E. P. McCartney, D. C. Garibaldi, M. P. Grant, N. T. Iliff, S. L. Merbs; Floppy Eyelid Syndrome: A New Surgical Approach. Invest. Ophthalmol. Vis. Sci. 2007;48(13):3574.
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Floppy eyelid syndrome (FES) presents with signs of chronic papillary conjunctivitis and easily everted upper eyelids. Contact of the cornea and tarsal conjunctiva with the pillow during sleep causes keratoconjunctivitis. Patients also present with eyelash ptosis, postulated to be related to abnormal tarsus and orbicularis causing insufficient support. Surgical techniques described to correct the eyelid laxity focus on lid tightening procedures. However, after tightening, the eyelid can stretch and evert again, posing a challenging management problem. Here we describe a successful new surgical technique for FES that stabilizes the eyelid with a porous polyethylene (PP) spacer.
PP lid spacers have been described for use in patients with lower lid retraction. For over 4 years, we have been placing these spacers in the upper eyelids of patients with FES, in combination with lid tightening, to prevent eyelid eversion. To date, we have placed more than 10 PP lid spacers for FES. After the levator tendon and tarsus are exposed through a lid crease incision and a wedge resection is performed, the spacer is cut and shaped to follow the contour of the upper tarsus. The implant is sutured into place over the tarsus and under the orbicularis. In addition to stabilizing the eyelid, the implant also provides a secure platform for lid margin rotation sutures to address the lash ptosis.
The PP lid spacer prevents eyelid eversion by adding structural support for the eyelid that is lacking if the lid is only tightened. Photos A and C show the lash ptosis and spontaneous eversion with manual elevation in a patient with FES. Photos B and D show the same patient post-operatively with excellent lid stability, resistance to eversion with manual elevation, and correction of the lash ptosis. We have found these implants useful for initial management and for management in patients with recurrence after tightening alone.
While many surgical techniques have been described to address FES, none involve the use of a PP implant as a lid stabilizer. We have used lid spacers successfully for over 4 years and believe they represent an attractive alternative to the standard surgical approach.
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