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.