Discussion:
When managing a case of keratoconjunctivitis, the differential diagnosis
can be broad; it may include dry eye syndrome, blepharitis, a multitude
of inflammatory processes, and infectious etiologies. It is imperative
to perform a detailed examination that includes a thorough slit lamp
examination. A unilateral case of keratoconjunctivitis recalcitrant to
medical therapy is highly unusual and requires a high index of suspicion
to look beyond the typical causes. Upper eyelid eversion is required to
identify conjunctival foreign bodies, evaluate the palpebral conjunctiva
for any papillary or follicular reactions, and rule out lagophthalmos.
Moreover, it is essential to screen for eyelid laxity through retraction
of both upper and lower eyelids. Findings of easy eversion, supple
tarsal plates, or abnormal retraction suggests FES2.
Lid retraction exceeding six millimeters may be flagged as
abnormal5.
Floppy Eyelid Syndrome (FES) is an incompletely understood condition
which was initially described in 1981 as papillary conjunctivitis and
conjunctival keratinization resulting from eyelids that easily and
spontaneously evert during sleep6. More recent
variations in nomenclature have been developed such as “lax eyelid
condition (LAC)” emphasizing the eyelid laxity and “lax eyelid
syndrome (LES)” when ocular surface disease is
involved1. FES is typically bilateral and often
associated with obesity, middle-age onset, higher predilection in males,
and obstructive sleep apnea1,2. This case is rather
unusual in that there is significant asymmetry as well as extreme left
upper eyelid laxity—15 mm of retraction beyond the superior orbital
rim.
Chan et al. describe Tape splint tarsorrhaphy (TST) as a novel,
non-surgical technique to help splint the eyelid closed in order to
treat persistent corneal epithelial defects4. The
benefits of this method include accessibility, reversibility, and
non-invasiveness. The patient is asked to close the eyelids, and while
the examiner retracts the patient’s eyebrow superiorly, the eyelid is
placed on stretch to eliminate the natural lid crease. A two-inch piece
of medical grade plastic tape is applied such that the tape covers the
entire eyelid. In other words, the bottom edge of the tape is placed on
the upper eyelid from the level of the lash-line up toward the brow. The
rigidity of the tape effectively creates a splint, preventing the eyelid
from opening, which in turn, results in an effective, non-surgical
tarsorrhaphy.
We describe a new use of the TST as a diagnostic and therapeutic
maneuver to determine the cause for unilateral keratoconjunctivitis
recalcitrant to medical therapy. Our patient was found to have extreme
left eyelid laxity and lagophthalmos, and application of the TST
resulted in dramatic improvement in signs and symptoms of
keratoconjunctivitis. Accordingly, clinicians may consider use of TST as
a helpful diagnostic and temporizing tool for patients presenting with
similar findings of keratoconjunctivitis non-responsive to standard
treatment. If TST application does not relieve symptoms, then exposure
keratopathy may be a less likely differential diagnosis, and the
treatment can easily be reversed without damage to the patient as
compared to a traditional tarsorrhaphy. Conversely, a positive response
suggests there could be a component of nocturnal lagophthalmos and
exposure.
Furthermore, all eye-care specialists can teach patients how to apply
the TST independently. Patients or caregivers can reapply the tape at
home without having to reschedule an appointment to the clinic.
Limitations of the TST include patient dependence to properly apply the
tape, potential for allergy to the tape adhesive, and instability of the
tape throughout the day or night. It is important to also recognize that
the TST is not a long-term solution to the problem; rather, surgical
procedures aimed at correcting lid laxity such as lateral tarsal strip,
full-thickness wedge incision, canthal tendon plication, medial lid
shortening, and lateral tarsorrhaphy are more definitive
options1,2,7.
TST is an excellent diagnostic and therapeutic maneuver to determine if
nocturnal corneal exposure is the potential source for a patient’s
corneal pathology4.