A 63-year-old female initially presented to her primary care doctor for “chronic red eye” and was started on over-the-counter olopatadine (Pataday, Alcon) eye drops for allergies twice a day (BID) in the left eye (OS) and was additionally prescribed topical polymyxin B/trimethoprim antibiotic drops four times a day (QID) OS. The patient did not improve and was referred to an optometrist for further evaluation.

The optometrist determined that the left eye had been erythematous, watery, and accompanied by burning sensations and blurry vision for three months, failing to improve with the above treatment. Past medical history was significant for developmental cognitive delay with a history for childhood sleep apnea and use of continuous positive airway pressure (CPAP). The patient is currently on bilevel positive airway pressure (BiPAP). Pertinent social history is relevant for requiring constant care by her mother due to her multiple chronic medical problems. Past ocular and family history were otherwise non-contributory.

Slit lamp examination revealed 1-2+ inferior bulbar conjunctival injection OS as well as bilateral 2-3+ inferior superficial punctate keratopathy (SPK). The tear volume was also found to be reduced in both eyes. The patient was diagnosed with punctate keratitis bilaterally (OU). She was advised to stop the above eyedrops and begin aggressive lubrication with artificial tears up to six times a day along with erythromycin ophthalmic ointment at bedtime. Additional recommendations included incorporating supplemental oral fish oil 1000 mg daily and increasing fluid intake. Despite therapeutic compliance, she returned three weeks later without subjective improvement and an ocular examination essentially unchanged. Tear break up time (TBUT) was noted to be three minutes in the right eye (OD) and two minutes OS. The patient was encouraged to continue conservative therapy and return for a recheck for dry eye syndrome. She was then prescribed a three-month supply of cyclosporine 0.05% (Restasis, Allergan) for use BID OU.

At the third optometry visit nearly one month later, the patient was frustrated and expressed only mild subjective improvement in her symptoms despite compliance with treatment. Although the tear film was noted to be normal on anterior segment examination, there was persistent SPK in the left eye. The patient was then referred to ophthalmology (D.B.K.) for a second opinion.

The patient presented to our clinic with persistent 2+ punctate keratopathy and 2+ conjunctival injection in the left eye. There was also peripheral corneal vascularization and subepithelial haze along the inferior one-fourth of the cornea in the left eye. Retraction of the upper eyelids revealed a fairly normal tarsal plate in the right eye (Figure 1A); however, there was profound flaccidity of the left upper eyelid, such that the upper eyelid margin was retractable 15 millimeters (mm) above the superior orbital rim (Figure 1B). There was also 1.5 mm of lagophthalmos in the left eye only (Figure 2). Schirmer 2 testing revealed 21 mm in the right and 22 mm in the left.

Despite the atypical presentation with extreme asymmetry in eyelid flaccidity, in light of the longstanding history for OSA, the diagnosis of floppy eyelid syndrome as a cause of lagophthalmos and exposure keratopathy of the left eye was made. The patient was counseled on these conditions and their association with obstructive sleep apnea (OSA). Temporizing treatment options were discussed, including continued aggressive lubrication, taping of the eyelids, tape splint tarsorrhaphy (TST), and moist chamber goggles. However, it was reiterated that surgical intervention would be necessary for definitive treatment.

The patient refused to have any surgical intervention, so tape splint tarsorrhaphy was chosen as a temporizing measure. The TST was placed over the left eyelid in the office (Figure 3) and the mother was instructed on how to apply it at home. She was counseled to maintain the TST during the day as much as possible as well as at bedtime.

The patient returned one month later with dramatic improvement in both signs and symptoms. The punctate keratopathy and conjunctival injection were resolved in the left eye; however, the inferior corneal vascularization and haze persisted. The patient and her mother were counseled extensively about the limitations of TST and that definitive treatment in the form of surgery to address the eyelid laxity would likely be needed if the problem recurred.

The patient missed the 3-month follow-up but returned in six months and was found to have recurrent keratoconjunctivitis due to poor compliance. Surgical correction of the FES with a lateral tarsal strip was reiterated and encouraged as a more definitive treatment toward resolution.