314
AMERICAN JOURNAL OF OPHTHALMOLOGY
September, 1990
Obstructive Sleep Apnea and the Floppy Eyelid Syndrome John
J. Woog, M.D.
Department of Ophthalmology, Massachusetts Eye and Ear Infirmary. Inquiries to John J. Woog, M.D., Ophthalmic Consultants of Boston, 50 Staniford St., Boston, MA 02114.
The floppy eyelid syndrome is characterized by the presence of an easily everted upper eyelid associated with keratoconjunctivitis.v" Typically, patients with floppy eyelid syndrome are overweight males who often display the habitus characteristic of a potentially fatal disorder that affects head and neck tissues, obstructive sleep apnea. Although reference to a "pickwickian disorder" has been made in the description of at least one patient with floppy eyelid syndrome," this report focused on the ophthalmic manifestations of floppy eyelid syndrome and not on an associated respiratory disorder. I examined three patients who had both floppy eyelid syndrome and obstructive sleep apnea.
Case 1 A 32-year-old man had a four-year history of conjunctivitis in both eyes and mild right upper eyelid blepharoptosis. Examination disclosed upper eyelid eversion upon application of mild upward traction (Fig. 1) and a fine superior tarsal papillary conjunctivitis. The patient was obese with a short bullneck appearance, and results of polysomnographic studies were consistent with obstructive sleep apnea.
Fig. 1 (Woog). Case 1. Upper eyelids evert easily with gentle upward traction.
Fig. 2 (Woog). Case 2. Everted left upper eyelid demonstrates velvety tarsal papillary conjunctivitis.
Case 2 A 22-year-old man had a six-year history of recurrent conjunctival injection in the left eye. Examination showed keratoconjunctivitis in the left eye with corneal vascularization and an easily everted left upper eyelid (Fig. 2). The patient's parents noted that he snored loudly, and characteristically slept on his left side with his left upper eyelid everted. Sleep evaluation findings were consistent with obstructive sleep apnea. Case 3 A 45-year-old obese man had previously undergone uvulopalatopharyngoplasty for obstructive sleep apnea. The patient had a threeyear history of irritation and injection in both eyes, particularly prominent upon awakening. Easily everted upper eyelids with a mild superior tarsal conjunctivitis were noted upon examination. Obstructive sleep apnea is characterized by periods of apnea and hypopnea during sleep, which occur as a result of upper airway obstruction.' Patients with obstructive sleep apnea demonstrate partial or complete collapse of the pharynx during inspiration, with symptoms ranging from loud snoring to unrefreshing sleep, daytime somnolence, morning headaches, and personality disturbances. Numerous medical problems have been associated with obstructive sleep apnea, including systemic and pulmonary hypertension, cardiac arrhythmias, and an increased frequency of automobile accidents.' Although the cause of pharyngeal collapse in
Vol. 110, No.3
Letters to the Journal
obstructive sleep apnea is poorly understood, it has been suggested that redundancy or abnormal laxity of oropharyngeal tissues may be involved in the pathogenesis of this disorder.' It is possible that similar defects in the tarsal plate or the canthal tendons may be important in the development of floppy eyelid syndrome. The concurrence of obstructive sleep apnea and floppy eyelid syndrome in my patients might suggest a common underlying abnormality involving the connective tissues of the head and neck. Recognition of a predilection for upper airway obstruction in at least one subset of patients with floppy eyelid syndrome may not only aid in patient treatment during corrective eyelid surgery, but may also ensure appropriate referral of these patients for further medical examination and therapy.
315
Isolated trochlear nerve palsy is the most common cause of acquired vertical strabismus in adults.' The cause often remains unknown despite appropriate investigation.f-" Most patients recover spontaneously within four months." Occasionally, patients with idiopathic trochlear nerve palsy do not regain superior oblique muscle function. In these cases, unremitting vertical diplopia without clear cause may prompt neuroimaging studies. A 62-year-old man reported the onset of vertical diplopia four years before an examination. To achieve fusion he assumed a left head
References 1. Culbertson, W. W., and Ostler, H. B.: Floppy eyelid syndrome. Am. J. Ophthalmol. 92:568, 1981. 2. Moore, M. B., Harrington, J., McCulley, }. P.: Floppy eyelid syndrome. Management including surgery. Ophthalmology 93:184,1986. 3. Goldberg, R., Seiff, S., McFarland, }., Simons, K., and Shorr, N.: Floppy eyelid syndrome and blepharochalasis. Am.}. Ophthalmol. 102:376, 1986. 4. Hanning, C D.: Obstructive sleep apnoea. Br. J. Anaesth. 63:477,1989. 5. Findley, L. J., Unverzagt, M. E., Suratt, P. M.: Automobile accidents involving patients with obstructive sleep apnea. Am. Rev. Respir. Dis. 138:337, 1988.
Magnetic Resonance Imaging of Superior Oblique Muscle Atrophy in Acquired Trochlear Nerve Palsy Jonathan
c. Horton, M.D.,
Rong-Kung Tsai, M.D.,
Charles L. Truwit, M.D., and William F. Hoyt, M.D. Departments of Neurological Surgery, Neurology, and Ophthalmology (J.CH., R.-K.T., W.F.H.) and Radiology (CL.T.), University of California, San Francisco. Inquiries to William F. Hoyt, M.D., Neuro-Ophthalmology Unit, University of California, San Francisco, San Francisco, CA 94143-0350.
Fig. 1 (Horton and associates). Serial 3-mm, Tl weighted, fat-saturation, gadolinium-enhanced images show selective atrophy of the right superior oblique muscle (small arrows). The left superior oblique muscle is normal in size (large arrows).
AMERICAN JOURNAL OF OPHTHALMOLOGY
September, 1990
Obstructive Sleep Apnea and the Floppy Eyelid Syndrome John
J. Woog, M.D.
Department of Ophthalmology, Massachusetts Eye and Ear Infirmary. Inquiries to John J. Woog, M.D., Ophthalmic Consultants of Boston, 50 Staniford St., Boston, MA 02114.
The floppy eyelid syndrome is characterized by the presence of an easily everted upper eyelid associated with keratoconjunctivitis.v" Typically, patients with floppy eyelid syndrome are overweight males who often display the habitus characteristic of a potentially fatal disorder that affects head and neck tissues, obstructive sleep apnea. Although reference to a "pickwickian disorder" has been made in the description of at least one patient with floppy eyelid syndrome," this report focused on the ophthalmic manifestations of floppy eyelid syndrome and not on an associated respiratory disorder. I examined three patients who had both floppy eyelid syndrome and obstructive sleep apnea.
Case 1 A 32-year-old man had a four-year history of conjunctivitis in both eyes and mild right upper eyelid blepharoptosis. Examination disclosed upper eyelid eversion upon application of mild upward traction (Fig. 1) and a fine superior tarsal papillary conjunctivitis. The patient was obese with a short bullneck appearance, and results of polysomnographic studies were consistent with obstructive sleep apnea.
Fig. 1 (Woog). Case 1. Upper eyelids evert easily with gentle upward traction.
Fig. 2 (Woog). Case 2. Everted left upper eyelid demonstrates velvety tarsal papillary conjunctivitis.
Case 2 A 22-year-old man had a six-year history of recurrent conjunctival injection in the left eye. Examination showed keratoconjunctivitis in the left eye with corneal vascularization and an easily everted left upper eyelid (Fig. 2). The patient's parents noted that he snored loudly, and characteristically slept on his left side with his left upper eyelid everted. Sleep evaluation findings were consistent with obstructive sleep apnea. Case 3 A 45-year-old obese man had previously undergone uvulopalatopharyngoplasty for obstructive sleep apnea. The patient had a threeyear history of irritation and injection in both eyes, particularly prominent upon awakening. Easily everted upper eyelids with a mild superior tarsal conjunctivitis were noted upon examination. Obstructive sleep apnea is characterized by periods of apnea and hypopnea during sleep, which occur as a result of upper airway obstruction.' Patients with obstructive sleep apnea demonstrate partial or complete collapse of the pharynx during inspiration, with symptoms ranging from loud snoring to unrefreshing sleep, daytime somnolence, morning headaches, and personality disturbances. Numerous medical problems have been associated with obstructive sleep apnea, including systemic and pulmonary hypertension, cardiac arrhythmias, and an increased frequency of automobile accidents.' Although the cause of pharyngeal collapse in
Vol. 110, No.3
Letters to the Journal
obstructive sleep apnea is poorly understood, it has been suggested that redundancy or abnormal laxity of oropharyngeal tissues may be involved in the pathogenesis of this disorder.' It is possible that similar defects in the tarsal plate or the canthal tendons may be important in the development of floppy eyelid syndrome. The concurrence of obstructive sleep apnea and floppy eyelid syndrome in my patients might suggest a common underlying abnormality involving the connective tissues of the head and neck. Recognition of a predilection for upper airway obstruction in at least one subset of patients with floppy eyelid syndrome may not only aid in patient treatment during corrective eyelid surgery, but may also ensure appropriate referral of these patients for further medical examination and therapy.
315
Isolated trochlear nerve palsy is the most common cause of acquired vertical strabismus in adults.' The cause often remains unknown despite appropriate investigation.f-" Most patients recover spontaneously within four months." Occasionally, patients with idiopathic trochlear nerve palsy do not regain superior oblique muscle function. In these cases, unremitting vertical diplopia without clear cause may prompt neuroimaging studies. A 62-year-old man reported the onset of vertical diplopia four years before an examination. To achieve fusion he assumed a left head
References 1. Culbertson, W. W., and Ostler, H. B.: Floppy eyelid syndrome. Am. J. Ophthalmol. 92:568, 1981. 2. Moore, M. B., Harrington, J., McCulley, }. P.: Floppy eyelid syndrome. Management including surgery. Ophthalmology 93:184,1986. 3. Goldberg, R., Seiff, S., McFarland, }., Simons, K., and Shorr, N.: Floppy eyelid syndrome and blepharochalasis. Am.}. Ophthalmol. 102:376, 1986. 4. Hanning, C D.: Obstructive sleep apnoea. Br. J. Anaesth. 63:477,1989. 5. Findley, L. J., Unverzagt, M. E., Suratt, P. M.: Automobile accidents involving patients with obstructive sleep apnea. Am. Rev. Respir. Dis. 138:337, 1988.
Magnetic Resonance Imaging of Superior Oblique Muscle Atrophy in Acquired Trochlear Nerve Palsy Jonathan
c. Horton, M.D.,
Rong-Kung Tsai, M.D.,
Charles L. Truwit, M.D., and William F. Hoyt, M.D. Departments of Neurological Surgery, Neurology, and Ophthalmology (J.CH., R.-K.T., W.F.H.) and Radiology (CL.T.), University of California, San Francisco. Inquiries to William F. Hoyt, M.D., Neuro-Ophthalmology Unit, University of California, San Francisco, San Francisco, CA 94143-0350.
Fig. 1 (Horton and associates). Serial 3-mm, Tl weighted, fat-saturation, gadolinium-enhanced images show selective atrophy of the right superior oblique muscle (small arrows). The left superior oblique muscle is normal in size (large arrows).
