Purpose: Patients with the floppy eyelid syndrome have chronic papilla
ry conjunctivitis with easily everted upper eyelids and a soft, pliant
upper tarsus. The purpose of this study is to describe the clinical f
eatures and the histopathologic correlate in a group of patients with
floppy eyelid syndrome. Methods: The authors examined eight patients w
ith floppy eyelid syndrome, four of whom underwent surgical management
with horizontal eyelid shortening. Eyelid tissue from these patients
was examined using light microscopy, electron microscopy, and immunohi
stochemistry and compared with controls with unrelated eyelid or orbit
al disorders. Results: Clinical findings included obesity or eye rubbi
ng, lash ptosis, and, less commonly, blepharoptosis. Two patients had
documented sleep apnea with abnormal sleep electroencephalogram. Light
microscopy of the surgical specimens showed chronic conjunctival infl
ammation, papillary conjunctivitis, and meibomian gland abnormalities,
including granuloma formation. Verhoeff's modified elastin stain demo
nstrated a marked decrease in the amount of elastin fibers in tarsus f
rom patients with floppy eyelid syndrome compared with controls. Immun
ohistochemical staining for elastin also showed a marked decrease of t
arsal elastin in floppy eyelid patients compared with controls. In con
trast, immunohistochemical stains showed that the distribution of coll
agen types I and III was similar between patients with floppy eyelid s
yndrome and controls. Electron microscopy demonstrated that tarsal col
lagen was comparable in patients and controls, and that there was a re
duced amount of tarsal elastin in floppy eyelid syndrome compared with
controls. Conclusions: These findings demonstrate that tarsal elastin
is decreased in the floppy eyelid syndrome, which may contribute to t
he laxity of the tarsus in this disorder.