Case Presentation:
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.