Kaleb Abbott, OD, MS, FAAO, joins host Damon Dierker, OD, FAAO, on Dry Eye Fireside Chat with a case that should make every optometrist a little suspicious of their next “routine” dry eye referral. Dr. Abbott is an assistant professor of ophthalmology at the University of Colorado School of Medicine, where he is faculty in both the dry eye clinic and the center for ocular inflammation.
Fast facts: floppy eyelid syndrome and obstructive sleep apnea
- Floppy eyelid syndrome features an upper eyelid that everts with minimal resistance, exposing the palpebral conjunctiva on light upward traction.
- In one cohort of 45 patients with floppy eyelid syndrome, 85% had obstructive sleep apnea (OSA), and most of those cases were severe.1
- A 2023 systematic review and meta-analysis confirmed the association between obstructive sleep apnea and floppy eyelid syndrome across the broader literature.2
- Normal tear meniscus height and normal Schirmer’s score argues against ocular graft-versus-host disease, which causes aqueous deficiency by attacking the lacrimal glands.
- Perfluorohexyloctane reduced signs and symptoms of dry eye disease compared with saline in the phase 3 GOBI trial.3
- Near-total meibomian gland loss removes the eye's natural lipid buffer against eyelid friction, changing which treatments actually help.
When the eyelid says more than the chart
A 78-year-old man walked in with a diagnosis already attached: ocular graft-versus-host disease (oGVHD), diagnosed 7 months after an allogenic bone marrow transplant that was now 4 years behind him, referred straight from hematology.
Everyone expected severe aqueous deficiency; the hallmark of oGVHD. What they got was a patient who unexpectedly needed a soft contact lens just to function, which is backward for anyone with garden-variety dry eye, and an exam that refused to match the paperwork.
At 6-foot-1 and slender, he did not fit the typical build for obstructive sleep apnea either, which made what Dr. Abbott found even harder to expect. He followed the mismatch instead of the referral, and the actual diagnosis turned out to be one most eyecare providers never think to screen for.
“Anything that's just a mismatch should perk your ears a little bit and start to make you think there could be something else at play.”
Diagnosis and management
Dr. Abbott did not get there by trusting the referral. Superior-only corneal and bulbar conjunctival staining pointed to friction rather than autoimmune dryness, and a simple tug on the upper lid delivered the real diagnosis: floppy eyelid syndrome, not graft-versus-host disease. He asked the two questions the slit lamp cannot answer: snoring, and gasping awake. Both, yes.
The patient volunteered daytime fatigue and morning headaches without being asked. Polysomnography 1 month later confirmed severe obstructive sleep apnea, CPAP followed, and the floppy eyelid syndrome eased right along with it. The friction itself still needed treating directly.
Dr. Abbott reached for perfluorohexyloctane, along with a bandage lens, punctal occlusion, and intranasal varenicline for tear secretion, rounding out a plan built around eyelid anatomy that ruled out most of the usual options.
“If we hadn't done a good exam and seen the floppy eyelids, we wouldn't have found that.”
Key takeaways
- Floppy eyelid syndrome is one of the more specific eye findings for flagging an undiagnosed systemic disease, not just a local irritant.
- An upper lid that everts with almost no resistance is a sleep-history trigger, not just an exam finding. Ask about snoring, gasping, daytime fatigue, and morning headaches.
- A patient who needs a contact lens for comfort, rather than complaining about wearing one, is telling you the problem is friction, not aqueous deficiency.
- Near-total meibomian gland loss leaves no natural lipid buffer against lid friction, which is where perfluorohexyloctane, punctal occlusion, and bandage lenses earn their place over standard dry eye therapy.
- A referral diagnosis that does not match the exam is a lead, not a formality. Follow the mismatch.
Final thoughts
This patient's dry eye workup ended up doing more than treating his eyes. Dr. Dierker put it plainly afterward: diagnosing the sleep apnea likely mattered more than anything done at the slit lamp, given the cardiovascular and stroke risk that comes with untreated severe OSA.
Watch the full conversation for Dr. Abbott's approach to the cases that refuse to fit a standard protocol, and for more on building findings like this into a routine exam, see Eyes On Eyecare's Simple Dry Eye Workup for Primary Care Optometrists.
This article was written by Keren Beki based on the recorded conversation between Drs. Dierker and Abbott.
