Exhausted elastin

As such, the correct next step for addressing her floppy eyelids wasn’t eye surgery or medication—it was a referral for a sleep test.

The patient did the test, which found that while she was sleeping, she stopped breathing 27 times per hour. On the apnea–hypopnea index, that yields a diagnosis of moderate-level OSA.

With this finding, the woman started using a continuous positive airway pressure (CPAP) machine, which delivers continuous air into the airway during sleep, preventing it from closing up. Along with some eye lubricants, nighttime eye patches, and a weight-loss plan, the woman’s condition rapidly improved. After two weeks, her eyelids were no longer inside out, and she could properly close her eyes. She was also sleeping better and no longer had daytime drowsiness.

Doctors don’t entirely understand the underlying mechanisms that cause floppy eyelid syndrome, and not all cases are linked to OSA. Researchers have hypothesized that genetic predispositions or anatomical anomalies may contribute to the condition. Some studies have found links to underlying connective tissue disorders. Tissue studies have clearly pointed to decreased amounts or abnormalities in the elastin fibers of the tarsal plate, the dense connective tissue in the eyelids.

For people with OSA, researchers speculate that the sleep disorder leads to hypoxic conditions (a lack of oxygen) in their tissue. This, in turn, could increase oxidative stress and reactive oxygen species in the tissue, which can spur the production of enzymes that break down elastin in the eyelid. Thus, the eyelids become lax and limp, allowing them to get into weird positions (such as inside out) and leading to chronic irritation of the eye surface.

The good news is that most people with floppy eye syndrome can manage the condition with conservative measures, such as CPAP for those with OSA, as did the woman in New York. But some may end up needing corrective surgery.