Ординатура / Офтальмология / Английские материалы / Diagnostic Atlas of Common Eyelid Diseases_Dutton, Gayre, Proia_2007‎

Ectropion (Contd.)

resection at the junction of the central and lateral thirds of the lid is preferred. In cases of paralytic ectropion, repair of the lower lid is usually not sufficient in itself to prevent the chronic corneal exposure. If there is significant facial droop, a vertical midface SMAS lift will help maintain eyelid position. Correction of the lagophthalmos with a gold weight implant, encircling silicone rod, or a lateral tarsorrhaphy may have to be added. Cicatricial ectropion when mild can often be repaired with a simple horizontal tightening procedure. For moderate ectropion combining horizontal shortening with a cheek elevation gives better results. When there is severe skin shortening, however, a full-thickness skin graft or myocutaneous flap will be needed. For mechanical ectropion attention to management of the conjunctival lesion is required, but additional eyelid shortening may be needed if the lid has become stretched.

REFERENCES

Bashour M, Harvey J. Causes of involutional ectropion and entropion—age related tarsal changes are the key. Ophthal Plast Reconstr Surg 2000; 16:131–141.

Benger RS, Frueh BR. Involutional ectropion: a review of the management. Ophthalmic Surg 1987; 18:136–139. Clement CI, O’Donnell BA. Medial canthal tendon repair for moderate to severe tendon laxity. Clin Experiment

Ophthalmol 2004; 32:170–174.

Crawford GJ, Collin JR, Moriarty PA. The correction of paralytic medial ectropion. Br J Ophthalmol 1984; 68:639–641. Dutton JJ. Atlas of ophthalmic surgery. Oculoplastic, Lacrimal, and Orbital Surgery. Vol. II. St Louis: Mosby Year Book,

1992: 94–113.

Frueh BR, Su CS. Medial tarsal suspension: a method of elevating the medial lower eyelid. Ophthal Plast Reconstr Surg 2002; 18:133–137.

Leatherbarrow B, Collin JR. Eyelid surgery in facial palsy. Eye 1991; 5:585–590. Mittelviefhaus H. Cicatricial ectropion in progressive skin diseases. Orbit 2001; 20:91–99.

Neuhaus RW. Anatomical basis of “senile” ectropion. Ophthal Plast Reconstr Surg 1985; 1:87–89.

Nowinski TS, Anderson RL. The medial spindle procedure for involutional ectropion. Arch Ophthalmol 1985; 103: 1750–1753.

Schellini SA, Sampaio Junior Ade A. Subperiosteal midface lift: an alternative to correct the cicatricial eyelid ectropion. Arq Bras Oftalmol 2005; 68:527–531.

Stasior OG. Involutional ectropion. Clin Plast Surg 1978; 5:593–596.

Stefanyszyn MA, Hidayat AA, Flanagan JC. The histopathology of involutional ectropion. Ophthalmology 1985; 92: 120–127.

Sullivan TJ, Collin JR. Medial canthal resection: an effective long-term cure for medial ectropion. Br J Ophthalmol 1991; 75:288–291.

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Entropion

INTRODUCTION Entropion is a turning inward of the eyelid margin. Like ectropion, the causes are numerous, but unlike the latter the results may be far more devastating to the eye. Occasionally entropion can be seen as a congenital malposition, usually associated with deformities of the eyelid and tarsus, such as the tarsal kink syndrome. Involutional entropion is the most common form seen in older individuals related to aging with horizontal and vertical laxity of eyelid suspensory structures, particularly the capsulopalpebral fascia. Entropion is more common when the tarsal plate is narrow allowing it to rotate inward. Cicatricial entropion is seen with shortening of the conjunctival surface from diseases such as cicatricial pemphigoid, Stevens-Johnson syndrome, trachoma, or from chemical burns. In mechanical entropion there may be a mass lesion that rotates the eyelid margin inward. Epiblepharon is sometimes included as a special type of entropion that is more mechanical than anything else. Here, the lower lid crease is not well formed and there is an upward override of the anterior lamella resulting in the entropion. Epiblepharon can also be an acquired deformity following trauma or surgery. Spastic entropion is anatomically similar to epiblepharon and is sometimes seen following ocular surgery associated with ocular irritation. Here there is associated loss of fixation between the anterior and posterior lamellae combined with eyelid laxity. With contraction of the orbicularis muscle the anterior lamella rides up and mechanically rotates the lid inward.

CLINICAL PRESENTATION Whatever the specific etiology of entropion the mucocutaneous border of the eyelid and the lashes are directed towards the globe. In some cases, as with cicatricial ocular pemphigoid, distortion of eyelid tissues may include a true trichiasis. However, in most cases the lashes are in a normal position relative to the lid margin, and the resulting corneal touch is secondary to the lid malposition. The clinical spectrum of entropion may vary from a mild, intermittent backward tilting of the marginal tarsus associated with only occasional corneal touch, to severe 180 degree inversion of the entire eyelid with the lashes and skin in full contact with the globe. The resulting ocular surface irritation is associated with conjunctival injection, reflex lacrimation and epiphora, and ocular discomfort from corneal epithelial disruption. Corneal abrasion and even frank ulceration may evolve if the condition is not corrected. A secondary blepharospasm is frequently present which exacerbates the condition.

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Entropion (Contd.)

TREATMENT The surgical correction of involutional entropion is directed at repair of the primary anatomical defect. If eyelid horizontal laxity is the only significant finding repair is achieved with simple horizontal lid shortening. When vertical lid laxity is a contributing factor, tightening or reattachment of the capsulopalpebral fascia either alone or in combination with horizontal tightening is required. Simultaneous reformation of the eyelid crease with internal sutures is an important part of this procedure. Correction of cicatricial entropion is aimed at restoration of the deficient posterior lamella. If minimal, this can be achieved by advancement of a skin and muscle flap or with full-thickness eyelid rotating sutures. If the tarsus is deformed an interpositional graft of tarsus from another lid or with cartilage, hard palate, or donor sclera will help reposition the lid margin. An effective procedure is marginal rotation by resecting a horizontal V-groove from the anterior tarsal face. For contraction of conjunctiva, mucous membrane or amniotic membrane grafting will release the cicatrix and allow realignment of the lid margin. Epiblepharon is corrected with eyelid sutures in infants, but in older children resection of an ellipse of skin and muscle with reformation of the lid crease gives more permanent results. Spastic entropion will sometimes resolve spontaneously. Temporary correction can be attained with botulinum toxin, 5 –10 units into the pretarsal muscle. Surgical repair requires tucking of the retractors with crease reformation.

REFERENCES

Barnes JA, Bunce C, Olver JM. Simple effective surgery for involutional entropion suitable for the general ophthalmologist. Ophthalmology 2006; 113:92–96.

Boboridis K, Bunce C, Rose GE. A comparative study of two procedures for repair of involutional lower lid entropion. Ophthalmology 2000; 107:959–961.

Danks JJ, Rose GE. Involutional lower lid entropion: to shorten or not to shorten? Ophthalmology 1998; 105:2065–2067. Dutton JJ. Atlas of ophthalmic surgery. Oculoplastic, Lacrimal, and Orbital Surgery. Vol. II. St Louis: Mosby Year Book,

1992: 114–143.

Ho SF, Pherwani A, Elsherbiny SM, Reuser T. Lateral tarsal strip and quickert sutures for lower eyelid entropion. Ophthal Plast Reconstr Surg 2005; 21:345–348.

Khan SJ, Meyer DR. Transconjunctival lower eyelid involutional entropion repair: long-term follow-up and efficacy. Ophthalmology 2002; 109:2112–2127.

Levine MR, Enlow MK, Terman S. Spastic entropion after cataract surgery. Ann Ophthalmol 1992; 24:195–198. Meadows AE, Reck AC, Gaston H, Tyers AG. Everting sutures in involutional entropion. Orbit 1999; 18:177–181. Rougraff PM, Tse DT, Johnson TE, Feurer W. Involutional entropion repair with fornix sutures and lateral tarsal strip

procedure. Ophthal Plast Reconstr Surg 2001; 17:281–287.

Shiu M, McNab AA. Cicatricial entropion and trichiasis in an urban Australian population. Clin Experiment Ophthalmol 2005; 33:582–585.

Steel DH, Hoh HB, Harrad RA, Collins CR. Botulinum toxin for the temporary treatment of involutional lower lid entropion: a clinical and morphological study. Eye 1997; 11:472–475.

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Epiblepharon

INTRODUCTION Epiblepahron is a congenital bilateral condition in which the anterior skin-muscle lamella of the eyelid rides up over the eyelid margin, turning it inward toward the globe. While this simulates entropion in appearance and consequences, it is quite different in its etiology. Epiblepharon is caused by the absence of the lower eyelid crease and the fascial attachments that unite together the anterior and posterior lamellae at that point. With contraction of the orbicularis muscle the anterior lamella rides upward over the lid margin, rotating the lashes inward. The entropion is typically worse in downgaze. Epiblepharon is more common in the Asian eyelid, especially when there is significant epicanthus, and in those with a high body mass index.

CLINICAL CHARACTERISTICS Epiblepharon appears as a redundant horizontal fold of pretarsal skin and orbicularis muscle that extends upward over the lower lid margin and lash line. In some patients the lid may appear completely normal in primary gaze, with the condition developing only on downgaze. In more severe cases the condition is manifest even in the primary gaze position. The overriding skin mechanically displaces the lash-bearing mucocutaneous border backward against the cornea. Symptoms include foreign body sensation, irritation, and reflex epiphora. More than half of affected children will have a with-the-rule astigmatism. However, up to 80% of affected children may have minimal or no ocular symptoms. Epiblepharon can also be seen as an acquired condition following trauma or surgery where there is disruption of fascial attachments between the anterior and posterior lamellae. It has also been described as a finding in Graves’ eye disease. Rarely epiblepharon can be seen in the upper eyelid as a developmental anomaly.

TREATMENT In many cases epiblepharon resolves spontaneously by the age of six or seven years, as the face elongates with growth. Treatment may be required, however, for significant ocular symptoms. This can be achieved in young children with the placement of full-thickness eyelid sutures of the Quickert-Rathbun type. This creates a scar band between the anterior and posterior lamellae that simulates the normal eyelid crease. In older children or where the fold is large, excision of an ellipse of skin with reformation of the crease will give better results.

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Epiblepharon (Contd.)

REFERENCES

Chang EL, Hayes J, Hatton M, Rubin PA. Acquired lower eyelid epiblepharon in patients with thyroid eye disease. Ophthal Plast Reconstr Surg 2005; 21:192–196.

Choo C. Correction of oriental epiblepharon by anterior lamellar reposition. Eye 1996; 10:545–547. Choo CT, Chan CM, Fong KS. Surgical management of upper lid epiblepharon. Eye 1998; 12:623–626.

Dutton JJ. Atlas of ophthalmic surgery. Oculoplastic, Lacrimal, and Orbital Surgery. Vol. II. St Louis: Mosby Year Book, 1992:118–121.

Hayasaka Y, Haysaka S. Epiblepharon with inverted eyelashes and high body mass index in Japanese children. J Pediatr Ophthalmol Strabismus 2005; 42:300–303.

Jeong S, Park H, Park YG. Surgical correction of congenital epiblepharon: low eyelid crease reforming technique. J Pediatr Ophthalmol Strabismus 2001; 38:356–358.

Jordan R. The lower-lid retractor in congenital entropion and epiblepharon. Ophthalmic Surg 1993; 24:494–496. Khwarg SI, Choung HK. Epiblepharon of the lower eyelid: technique of surgical repair and quantification of excision

according to the skin fold height. Ophthalmic Surg Lasers 2002; 33:280–287.

Khwarg SI, Lee YJ. Epiblepharon of the lower eyelid: classification and association with astigmatism. Korean J Ophthalmol 1997; 11:111–117.

Lemke BN, Stasior OG. Epiblepharon. An important and often missed diagnosis. Clin Pediatr (Phila) 1981; 20:661–662. O’Donnell BA, Collin JR. Congenital lower eyelid deformity with trichiasis (epiblepharon and entropion). Aust N Z J

Ophthalmol 1994; 22:33–37.

Park RI, Meyer DR. Acquired lower eyelid epiblepharon. Am J Ophthalmol 1996; 122:449–451.

Quickert MH, Wilkes TD, Dryden RM. Nonincisional correction of epiblepharon and congenital entropion. Arch Ophthalmol 1983; 101:778–781.

Serafino M, Bottoli A, Nucci P. Correction of congenital entropion of the lower eyelid: incisional versus rotational surgery. Eur J Ophthalmol 2005; 15:536–540.

Woo KI, Yi K, Kim YD. Surgical correction for lower lid epiblepharon in Asians. Brit J Ophthalmol 2000; 84:1407–1410.

Epicanthal Folds

INTRODUCTION Epicanthal folds are small webs of skin that contour around the medial canthal region. They can be seen as an isolated finding or in association with other facial anomalies such as the blepharophimosis syndrome or Downs syndrome. They can also be seen as a racial variation, particularly in some East Asian and Southeast Asian eyelids, and in Native Americans and the Khoisan of Southern Africa. They can also be seen in young children as a normal finding before the nasal bridge elevates. Epicanthal folds are categorized by anatomic location, and are termed epicanthus inversus, e. palpebralis, e. tarsalis, and e. supraciliaris.

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Epicanthal Folds (Contd.)

CLINICAL CHARACTERISTICS Epicanthal folds vary from hardly noticeable to very strongly developed. They usually diminish with age as the nasal bridge changes in height and contour. In epicanthus inversus the fold of skin takes origin from the lower eyelid and extends to the medial canthal angle, covering the canthal angle and caruncle. It confers a rounded contour to the lower eyelid, and the fold often obscures the lid margin medially. It may be associated with a limited from of epiblepharon. In epicanthus palpebralis the skin fold extends from the tarsal region of the upper lid to the margin of the lower lid, giving an abnormal contour to the upper eyelid margin. This type tends to improve with growth of the midface. Epicanthus tarsalis is a fold that extends from the pretarsal upper eyelid skin to the medial canthal angle, and is a normal finding in the Asian eyelid. In epicanthus supraciliaris the fold originates from just below the medial eyebrow and extends to the medial canthus in the region of the lacrimal sac.

TREATMENT Epicanthal folds are usually only of cosmetic importance, but in some cases they may obscure the medial visual field. When correction is indicated the treatment is surgical. Many different procedures are available, but all rely on tissue rearrangement to lengthen the vertical component of the fold at the expense of the horizontal width. These include the modified Y to V plasty, the Z-plasty, and combinations of Z-plasty and Y to V rearrangements.

REFERENCES

Cho BC, Lee KY. Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids. Plast Reconstr Surg 2002; 110:293–300.

de Cunha RP, Moreira JB. Ocular findings in Down’s syndrome. Am J Ophthalmol 1996; 122:236–244. Jordan DR, Anderson RL. Epicanthal folds. A deep tissue approach. Arch Ophthalmol 1989; 107:1532–1535.

Kao YS, Lin CH, Fang RH. Epicanthoplasty with modified Y-V advancement procedure. Plast Reconstr Surg 1998; 102:1935–1841. McCord CD Jr. The correction of telecanthus and epicanthal folds. Ophthalmic Surg 1980; 11:446–454.

Mustarde JC. The treatment of ptosis and epicanthal folds. Br J Plast Surg 1959; 12:252–258.

Nowinski TS. Epicanthal folds and blepharophimosis: a new technique. Trans PA Acad Ophthalmol Otolaryngol 1988; 40:706–712. Park JI. Modified Z-epicanthoplasty in the Asian eyelid. Arch Facial Plast Surg 2000; 2:43–47.

Yoo WM, Park SH, Kwang DR. Root Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 2003; 111:2476–2477.

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Essential Blepharospasm

INTRODUCTION Essential blepharospasm (EB) is a bilateral focal dystonia of idiopathic origin. The condition usually affects patients in their fifth to sixth decades but can be seen in younger individuals, even in their teens. It is two to three times more common in females. In 33% of cases some familial occurrence of dystonia can be elicited, suggesting a possible genetic predisposition.

Some evidence suggests a central defect in the coordination of ocular and periocular sensory information and motor response in the orbicularis muscle. EB is usually seen as an isolated finding. However, in many cases it progresses to include adjacent focal dystonias, most commonly oromandibular dystonia. This complex of EB and oromandibular dystonia is referred to as Meige’s syndrome. Cervical dystonia is also common in these patients.

CLINICAL CHARACTERISTICS The disease usually begins insidiously with increased frequency of blinking, and slowly progresses to forceful, sustained eyelid closure. In some cases the disorder may have a sudden onset. The orbicularis muscle shows episodic spasms that vary from mild to extreme. The procerus and corrugator muscles may also be involved. The duration of eye closure may vary from seconds to minutes, and can result in significant visual disability and even functional blindness. Nearly half of affected patients progress to oromandubular dystonia, which includes the mid and lower facial muscles. The association of blepharospasm and oromandubular dystonia is often referred to as Meige’s Syndrome. Spasms are exacerbated by stress, and can sometimes be relieved by sensory tricks such as whistling or touching a part of the face.

TREATMENT The most affective treatment currently available is chemodenervation with botulinum toxin. The latter blocks neuromuscular transmission by inhibiting release of acetyl choline at peripheral nerve endings. Onset is usually within three to five days, and the duration of effect is typically about three months. For the 4% to 5% of patients who do not respond to botulinum toxin type A (Botox®) or who develop resistance to it, botulinum toxin type B (Myobloc®) is also available, and generally works well in most cases. When chemodenervation fails to give adequate results pharmacological agents such as benzodiazepines or anticholinergic agents can be added. For those who do not obtain satisfactory control of spasms on these regimens, surgical myectomy with removal of orbicularis muscle from the upper eyelids combined with brow fixation, will usually produce acceptable results.

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Essential Blepharospasm (Contd.)

REFERENCES

Anderson RL, Patel BC, Holds JB, Jordan DR. Blepharospasm: past, present, and future. Ophthal Plast Reconstr Surg 1998; 14:305–317.

Aoki KR, Guyer B. Botulinum toxin type A and other botulinum serotypes: a comparative review of biochemical and pharmacological actions. Europ J Neurol 2001; 8(suppl 5):21–29.

Ben Simon GJ, McCann JD. Benign essential blepharospasm. Int Ophthalmol Clin 2005; 45:49–75.

Bradley EA, Hodge DO, Bartley GB. Benign essential blepharospasm among residents of Olmsted County, Minnesota, 1976 to 1995: an epidemiologic study. Ophthal Plast Reconstr Surg 2003; 19:177–181.

Dutton JJ, Buckley EG. Long-term results and complications of botulinum toxin in the treatment of blepharospasm. Ophthalmology 1988; 95:1529–1534.

Dutton JJ. Acute and chronic effects of botulinum toxin in the management of blepharospasm. In Jankovic J, Halleatt M, eds, Therapy With Botulinum Toxin. New York: Marcel Dekker, 1994:199–209.

Dutton JJ. Botulinum-A toxin in the treatment of craniocervical muscle spasms: shortand long-term, local and systemic effects. Surv Ophthalmol 1996; 41:51–65.

Herz NL, Yen MT. Modulation of sensory photophobia in essential blepharospasm with chromatic lenses. Ophthalmology 2005; 112:2208–2211.

Patel BC. Surgical management of essential blepharospasm. Otolaryngol Clin North Am 2005; 38:1075–1098.

Euryblepharon

INTRODUCTION Euryblepharon is a very rare congenital anomaly of the palpebral fissure. It is distinguished from ankyloblepharon where the lid margins are fused together to varying degrees, and from cryptophthalmos where the eyelids are not formed but skin extends across and over a deformed eye. It may be unilateral or bilateral and is not typically associated with other congenital anomalies or syndromes, nor does there appear to be any familial tendency. It has been suggested that euryblepharon results from a

developmental hypoplasia or absence of the palpebral and lacrimal portions of the orbicularis muscle.

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Euryblepahron (Contd.)

CLINICAL CHARACTERISTICS In euryblepharon the palpebral fissure is elongated horizontally. It may involve the lower and/or upper eyelid, and can be bilateral or unilateral. The lateral portion of the lower eyelid becomes somewhat redundant and ectropic, producing a downward droop giving the patient an antimongaloid slope to the palpebral fissure. The lateral canthal tendon is lax or not developed so that there is also significant laxity of the lower eyelid. The condition can be associated with lagophthalmos and corneal exposure. Rarely, other findings may include a double row of meibomian gland orifices or a lateral displacement of the punctum and canaliculus. Some degree of vertical eyelid skin shortening is also commonly seen.

TREATMENT Treatment of euryblepharon is surgical and is indicated for exposure symptoms or for cosmetic improvement. A lateral canthoplasty with tightening and repositioning of the lateral canthal tendon is often sufficient. For excessive horizontal lid lengthening, a full-thickness wedge resection maybe needed to correct the ectropion. When vertical shortening causes significant lagophthalmos, skin grafts may be required.

REFERENCES

Keipert JA. Euryblepharon. Br J Ophthalmol 1975; 59:57–58.

D’Esposito M, Magli A, Del Prete A. Genetic study and surgical correction of euryblepharon. Ophthalmologica 1979; 178:396–403.

McCord CD Jr, Chapell J, Pollard ZF. Congenital euryblepharon. Ann Ophthalmol 1979; 11:1217–1224. Ruban JM, Baggio E. Surgical treatment of congenital eyelid malpositions in children. J Fr Ophthalmol 2004;

27:304–326.

Floppy Eyelid Syndrome

INTRODUCTION The Floppy Eyelid Syndrome primarily affects obese individuals with a male predominance. The cause of the disease remains unknown and histological examination of the softened and redundant tarsal plate has not suggested any conclusive etiology. A mild chronic inflammatory infiltrate has been reported in some cases, but it is not clear if this was a primary cause or a secondary effect. The tarsal plate and skin show a decreased amount of elastin fibers. The syndrome and its clinical spectrum results from loss of physical integrity of the tarsus, perhaps in part related to habitual sleeping on the involved sides in patients with excessive weight. The condition is also associated with obstructive sleep apnea.

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Floppy Eyelid Syndrome (Contd.)

CLINICAL CHARACTERISTICS More than 75% of patients with Floppy Eyelid Syndrome are males between the ages of 30 and 80 years. Obesity is a nearly constant finding, observed in 96% of cases. A history of sleeping on the face, especially on the involved side is typical. In most cases only the upper eyelid is involved, and in 60% of cases the condition is bilateral. Eyelash ptosis and loss of lash parallelism appear to be constant findings. Associated lower eyelid laxity is seen in 50% of affected patients, and in some a frank floppy lower eyelid will be present. Ocular symptoms include ptosis, ocular irritation, and foreign body sensation, especially upon waking up in the morning. Tear film deficiency is seen in most patients. Conjunctival injection, eyelid swelling, and a mucoid discharge are characteristics resulting from repeated nocturnal eyelid eversion. Chronic papillary conjunctivitis is typical with keratinization and epithelial thickening. Less commonly, superficial punctate keratopathy and a superior pannus result. The tarsus is soft and redundant, and shows marked laxity.

TREATMENT When the condition is mild topical lubrication combined with taping the eyelids closed at night, or applying an eye shield may provide some relief. In more severe cases, however, surgery will be needed. A full-thickness resection of the eyelid amounting to one-third to one-half of the horizontal length with primary layered closure is curative. This not only prevents spontaneous eyelid eversion during sleep, but also corrects the eyelid ptosis.

REFERENCES

Dufek MA, Shechtman DL. Floppy eyelid syndrome: a diagnostic dilemma. J Am Optom Assoc 1999; 70:450–454. Dutton JJ. Surgical management of floppy eyelid syndrome. Am J Ophthalmol 1985; 99:557–560.

Klapper SR, Jordan DR. Floppy eyelid syndrome. Ophthalmology 1998; 105:1582.

Langford JD, Lindberg JV. A new physical finding in floppy eyelid syndrome. Ophthalmology 1998; 105:165–169.

Liu DT, Di Pascuale MA, Sawai J, Goa YY, Tseng SC. Tear film dynamics in floppy eyelid syndrome. Invest Ophthalmol Vis Sci 2005; 46:1188–1194.

McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnea. Clin Experiment Ophthalmol 2000; 28:125–126.

McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg 1997; 13:98–114. McNab AA. Floppy eyelid syndrome. Ophthalmology 1998; 105:1977–1978.

Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthal Plast Reconstr Surg 2002; 18:370–372. Schlotzer-Schrehardt U, Stojkovic M, Hofmann-Rummelt C, et al. The pathogenesis of floppy eyelid syndrome: involvement

of matrix metaloproteins in elastic fiber degeneration. Ophthalmology 2005; 112:694–704.

Valenzuela AA, Sullivan TJ. Medial upper eyelid shortening to correct medial eyelid laxity in floppy eyelid syndrome: a new surgical approach. Ophthal Plast Reconstr Surg 2005; 21:259–263.

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