Clinical and diagnostic criteria for hyperextensible eyelids

Analysis of clinical manifestations of involutional eyelid deformities in patients with indications for blepharoplasty revealed that almost one in four (24.7%) had clinical signs of hyperextensible eyelids (HES): flaccid, thin, well-dislocated eyelid tissues that easily stretch in vertical and horizontal directions, may evert at night with floppy eyelid syndrome (FES), multiple skin folds - festooned eyelids, positive ‘pinch test’ in hypotony, etc. Despite the great variability of clinical manifestations, common pathogenetic mechanisms of HES have been established: damage to elastic and collagen fibres, chronic aseptic inflammation, impaired haemomicrocirculation in tissues of varying degrees of severity. The danger of HES lies in the reduction of the supporting properties of tissues and a high risk of postoperative complications associated with eyelid retraction. Therefore, the problem of identification of such patients, development of diagnostic tests for planning and predicting the results of blepharoplasty remains relevant.

Purpose of a study: to improve the efficiency of diagnostics of patients with HES when planning blepharoplasty operations.

Material and methods. A total of 352 patients with involutional eyelid deformities were analysed. The age of the study participants ranged from 31 to 68 years, the mean age was (47.0 ± 9.6) years. Out of the total number of examined patients, 87 (24.7%) cases of combination of eyelid involutional deformities with signs of eyelid hyperextensibility were revealed: blepharochalasis was diagnosed in 40 (11.4%) patients, hyperelastosis in 28 (7.9%), and blepharochalasis was combined with hyperelastosis in 19 (5.4%) patients. The control group included 53 patients with involutional eyelid deformities without signs of HES. The examination was performed using four tests: 1) vertical distraction of the upper eyelids (McNab A.A., 1997); 2) vertical distraction of the lower eyelids (McNab A.A., 1997); 3) horizontal distraction of the upper eyelids (Iyengar S.S., Khan J.A., 2007); 4) dystopia of the outer corner of the eye (Grishchenko S.V., 2013).

Results. Analysis of quantitative indicators of diagnostic tests irrespective of the age of the study participants made it possible to reveal reliable values of the norm and in case of HES in millimetres. Thus, in involutional eyelid deformation without HES, the maximum linear values were: 1) vertical upper eyelid distraction test – (6.31 ± 0.47) mm; 2) vertical lower eyelid distraction (5.21 ± 0.58) mm; 3) horizontal upper eyelid distraction – (4.62 ± 0.55) mm; 4) external eye angle dystopia – (5.23 ± 0.50) mm, while in patients with involutional eyelid deformities combined with HES, the minimum values in similar tests were: (7.90 ± 0.79); (7.72 ± 0.73); (6.27 ± 0.55) and (5.41 ± 0.50) mm, respectively.

Conclusions. Eyelid hyperextensibility occurs in almost every fourth patient with involutional eyelid deformities and is an indication for blepharoplasty. Due to impaired tissue support function, these individuals have a high risk of postoperative eyelid retraction. Eyelid hyperextensibility is a characteristic sign of blepharochalasis and hyperelasticity of tissues and can be diagnosed using objective tests: 1) vertical distraction of the upper eyelid (McNab test) more than 6.8 mm; 2) vertical distraction of the lower eyelid (McNab test) more than 5.8 mm; 3) horizontal distraction of the upper eyelid more than 5.1 mm; 4) dystopia of the external eye corner more than 5.7 mm.

1. Culbertson W.W., Ostler H.B. The floppy eyelid syndrome. Am J Ophthalmol. 1981; 92: 568-75.

2. Vishal Thakur, Deepa Shrestha, Aarti Bishnoi, Debajyoti Chatterjee, Valliappan Muthu, Keshavamurthy Vinay. Floppy Eyelid Syndrome. Indian J Dermatol. 2022 Mar-Apr; 67(2): 179-181. doi: 10.4103/ijd.ijd_751_21.

3. Van den Bosch W.A., Lemij H.G. The lax eyelid syndrome. Br J Ophthalmol. 1994; 78:666-670.

4. Krinitsyna E.A., Fettser E.I., Grusha Ya.O. Patogeneticheskiye i klinicheskiye aspekty sindroma giperrastyazhimyh vek (floppy eyelid syndrome) [Pathogenetic and clinical aspects of floppy eyelid syndrome]. Vestnik oftal'mologii – Russian Annals of Ophthalmology. 2021; 137(1): 102-105. doi: 10.17116/oftalma2021137011102 (in Russ.).

5. Ezra D.G., Beaconsfield M., Sira F. The associations of floppy eyelid syndrome: a case control study. Ophthalmology. 2010; 117: 851-838. doi: 49.4916/j.ophtha.2009.09.049

6. Lee C.C., Lai H.T., Kuo Y.R. Floppy eyelid syndrome: an unfamiliar entity for plastic surgeons. Ann Plast Surg. 2018; 80(2S): 40-47. doi:49.4997/sap.0000000000003411

7. Hashemi H., Rastad H., Emamian M.H., Fotouhi A. Floppy eyelid syndrome and its determinants in Iranian adults: a population-based study. Eye Contact Lens. 2017; 133: 3406-3449. doi: 49.4997/icl.0000000000000497

8. Fox T.P., Schwartz J.A., Chang A.C, et al. Association between eyelid laxity and obstructive sleep apnea. JAMA Ophthalmol. 2017; 345: 4955-4961.

9. Razvan Cristescu Teodor, Florin Dumitru Mihaltan. Eyelid laxity and sleep apnea syndrome: a review. Rom J Ophthalmol. 2019 Jan-Mar; 63(1): 2-9.

10. Wang P., Yu D.-J., Feng G., et al. Is floppy eyelid syndrome more prevalent in obstructive sleep apnea syndrome patients? J Ophthalmol. 2016 Jun 5; 2016: 6980281. doi: 10.1155/2016/6980281

11. Salinas R., Puig M., Fry C.L., Johnson D.A., Kheirkhah A. Floppy eyelid syndrome: A comprehensive review. Ocul Surf. 2020 Jan; 18(1): 31-39. doi: 10.1016/j.jtos.2019.10.002

12. De Gregorio A., Cerini A., Scala A., Lambiase A., Pedrotti E., Morselli S. Floppy eyelid, an under-diagnosed syndrome: a review of demographics, pathogenesis, and treatment. Ther Adv Ophthalmol. 2021 Dec 5; 13: 25158414211059247. doi: 10.1177/25158414211059247

13. Gorenkov R.V., Ryabtseva A.A., Agafonov B.V. et al. Sindrom «sukhogo glaza» v obshchey vrachebnoy praktike [Dry eye syndrome in general medical practice]. Effektivnaya farmakoterapiya. 2019; 15(33): 30-36 (in Russ.). doi: 10.33978/2307-3586-2019-15-33-30-36

14. Ito O., Suzuki S., Park S., Muneuchi G., Kamazoe Т., Saso Y., Onodera M., Hata Y. Usefulness of Palatal Mucoperiosteal Grafts for Artificial Eye Socket Contracture. Ann of Plast Surg. 2003; 51(3): 278-282.

15. Yvon C., Hunt S., Malhotra R. The Importance of Identifying Meibomian Gland Inversion in Patients with Floppy Eyelid Syndrome. Ophthalmic Plast Reconstr Surg. 2023 Mar-Apr; 39(2): 156-161. doi: 10.1097/IOP.0000000000002268

16. Hirmand H., Codner M.A., McCord C.D., Hester R.T. Jr., Nahai F. Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system. Plast Reconstr Surg. 2002 Aug; 110(2): 620-8; discussion 629-34. doi: 10.1097/00006534-200208000-00040

17. McNab A.A. Floppy eyelid syndrome and obstructive sleep apnea. Ophthalplastreconstr Surg. 1997; 13(2): 98-114.

18. McNab A.A. The eye and sleep apnea. Sleep Med Rev. 2007; 11: 269-476.

19. Iyengar S.S., Khan J.A. Quantifying upper eyelid laxity in symptomatic floppy eyelid syndrome by measurement of anterior eyelid distraction. Ophthalmic Plast Reconstr Surg. 2007; 133: 255.

20. Grishchenko S.V, Borkhunova E.N. Klinicheskiye proyavleniya i morfologicheskiye priznaki involyutsionnyh deformatsiy vek [Clinical manifestations and morphological signs of involutional eyelid deformities]. Eksperimental'naya i klinicheskaya dermatokosmetologiya – Experimental and Clinical Dermatocosmetology. 2011; 1: 36-42. (In Russ.).

21. Grishchenko S.V., Borkhunova E.N., Filatova I.A., Vissarionova I.V. Stareniye vek: klinicheskiye, morfologicheskiye proyavleniya i osobennosti mikrotsirkulyatsii [Eyelid aging: clinical, morphological manifestations and peculiarities of microcirculation]. Uspekhi gerontologii – Advances in Gerontology. 2011; 24(2): 331-339. (In Russ.).

22. Filatova I.A., Kondratieva Yu.P., Mohammad I.M., Shemetov S.A., Maybogin A.M. Khirurgicheskoye lecheniye sindroma “khlopayushchikh vek” [Surgical treatment of the floppy eyelid syndrome]. Rossiyskiy oftal'mologicheskiy zhurnal – Russian Ophthalmological Journal. 2023;16(1):96-100. doi: 10.21516/2072-0076-2023-16-1-96-100 (In Russ.)