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A 48-year-old white male presented with chronic photophobia, redness and pain. His best-corrected
visual acuity measured 20/40 O.D. and 20/200 O.S. His cornea showed grade 3+ staining (O.S. > O.D.) and
grade 3+ injection and chemosis, but no discharge. The anterior chamber was deep and quiet. The fundus
examination was unremarkable.
Previously, the patient was treated with artificial tears, corticosteroids, cyclosporine, allergy medications, oral doxycycline,
antibiotic ointments and combination antibiotic/steroid drops—none of which completely alleviated his symptoms. Additionally,
he was prescribed hypertonic drops and ointment, which reduced his recurrent corneal erosion (RCE), but did not improve his
overall condition.
Corticosteroid drops most effectively improved his signs and symptoms, but did not facilitate complete resolution. More
specifically, whenever the patient tapered the steroids, he experienced a recurrence of symptoms—even in the presence of
continued dosing. Antibiotic ointments also helped, but could not fully improve his condition. In toll, the patient periodically
experienced these symptoms for three years.
So, what appears to be the underlying cause?
In cases of chronic superficial punctate keratitis (SPK) and conjunctival injection, consider a diagnosis of floppy eyelid
syndrome (FES). In this case, the lack of a tight eyelid resulted in constant inflammation to the cornea and conjunctiva, as
evidenced by the corneal and conjunctival edema and staining. Additionally, we noted that his eyelids were extremely "elastic,"
and could be flipped with one finger or even pulled two inches away from his face. Keep in mind that FES is more common in
overweight, middle-aged males—as was the case in our patient.¹ Also, our patient had a history of sleep apnea, which is
consistent with FES.²
The only treatment option for severe FES is surgical repair. Accordingly, our patient underwent surgery two weeks ago and
is already showing significant visual and symptomatic improvement.
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