Prospective Evaluation of Floppy Eyelid Syndrome at Baseline and after CPAP Therapy

Floppy eyelid syndrome (FES) is an ocular manifestation of obstructive sleep apnea (OSA), but no studies have analyzed whether it can be improved by nocturnal continuous positive airway pressure (CPAP) therapy. The aim of this study was to analyze the effect of CPAP on FES by comparing objective measurements before and after 6 months of CPAP therapy.

We conducted a prospective study of 47 patients (74.5% males) with newly diagnosed OSA at a secondary care Portuguese hospital who underwent objective diagnostic testing for FES (upper eyelid eversion for >6 seconds and tarsal conjunctival exposure and upper eyelid laxity ≥1.5 mm). Patients with hyperelastic eyelid or FES were re-evaluated by the same ophthalmologist (blinded to the patients' condition) after 6 months of CPAP therapy.

Mean apnea hypopnea index (AHI), analyzed as number of events per hour, was 28.7 ± 18.6 overall and 42.8 ± 20.0 in the supine position. Thirty-four percent of patients had FES. Mean AHI in the supine position was significantly higher in patients with FES (p = .041) and was an independent predictor of FES (p = .034; OR = 0.48). Severe OSA was significantly associated with FES (p = .023). FES resolved in 53.8% of patients after CPAP therapy. Patients with non-reversible FES had more severe OSA and worse airway access according to the Mallampati classification (from class I: visualization of soft palate and entire uvula, to class IV: soft palate not visible).

A higher AHI in the supine position may be predictive of FES. CPAP therapy might reverse FES and patients with non-reversible FES appear to have more severe OSA and a worse airway access.