|Year : 2020 | Volume
| Issue : 2 | Page : 127-132
Prevalence, risk factors, and morbidity of eyelid laxity in elderly Egyptian population
Shymaa I Saad1, Mohamed A Ragab2, Ihab M Osman2
1 Ophthalmolgy Resident, Imbaba Ophthalmology Hospital, Giza, Egypt
2 Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||02-Jan-2020|
|Date of Decision||08-Mar-2020|
|Date of Acceptance||22-Mar-2020|
|Date of Web Publication||26-Jun-2020|
BSC, MSC Shymaa I Saad
94 S Street, Hadayek El Ahram, Giza 12572
Source of Support: None, Conflict of Interest: None
Purpose The aim of this study was to evaluate the age and its relation to lid laxity and ocular surface disorders as well as the lid laxity prevalence in an elderly Egyptian population.
Setting The study was conducted at the Department of Ophthalmology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
Patients and methods The study included 400 patients presenting to the Outpatient Eye Clinic of Alexandria Main University Hospital, Alexandria, Egypt, from April 2018 to April 2019. A cross-sectional survey of patients above 55 years old was done. Clinical data were gathered from a questionnaire. Upper and lower eyelid laxity was clinically graded. In addition, tear breakup time test was done to evaluate dryness.
Results The study was conducted on 799 eyes. The prevalence of lid laxity in the right lower and upper lids was 51.1 and 14.8%, respectively, whereas in left lower and upper lids, it was 50 and 14.7%, respectively. There was a negative significant correlation between tear breakup time and lid laxity in the right lower and upper lids and in the left lower lid (P<0.001).
Conclusion Eyelid laxity was prevalent in this elderly Egyptian population. Its presence was associated with ocular surface morbidity. This suggests that dynamic eyelid testing should be incorporated into the ophthalmic examination in patients with ocular surface discomfort.
Keywords: eyelid, laxity, elderly, dry eye
|How to cite this article:|
Saad SI, Ragab MA, Osman IM. Prevalence, risk factors, and morbidity of eyelid laxity in elderly Egyptian population. Delta J Ophthalmol 2020;21:127-32
|How to cite this URL:|
Saad SI, Ragab MA, Osman IM. Prevalence, risk factors, and morbidity of eyelid laxity in elderly Egyptian population. Delta J Ophthalmol [serial online] 2020 [cited 2021 Oct 16];21:127-32. Available from: http://www.djo.eg.net/text.asp?2020/21/2/127/287458
| Introduction|| |
As life expectancy increases worldwide (∼600 million people are aged 60 years and older), involutional and chronic eye diseases are becoming increasingly important in the spectrum of ophthalmological diseases. The involutional changes that result in eyelid pathology include ectropion and entropion, dermatochalasis, and aponeurotic ptosis .
The characterizing feature of ocular adnexal tissue aging is advanced increase of laxity and loss of tone, which leads to sagging eyelids. Genetic source, which cannot be modified by human behavior, is a part of the intrinsic aging mechanism. However, extrinsic aging can be caused by parameters, such as alcohol use, chronic exposure to sunlight, smoking, and nutrition .
Eyelid laxity refers to a clinical picture of easily distractible upper and/or lower eyelid margins away from the eye . Patients with this condition generally complain of nonspecific irritation and foreign body sensation ,. It can occur owing to natural aging, mechanical rubbing/forceful eyelid manipulation, hyperelasticity, postinflammatory response, or blepharochalasis. There are little data on the prevalence of eyelid laxity in the general population. Part of the reason is likely that dynamic physical testing in the form of eyelid manipulation is needed to reach this diagnosis. Dynamic eyelid testing is rarely performed in the routine evaluation of the ophthalmic patient unless there is obvious eyelid malposition .
The present study aimed to evaluate the prevalence of eyelid laxity and age as risk factor for its presence. In addition, the correlation of lid laxity to ocular surface symptoms in an elderly Egyptian population was evaluated.
| Patients and methods|| |
This cross-sectional study was carried out on 400 patients presenting to the Outpatient Eye Clinic of Alexandria Main University Hospital, Alexandria, Egypt from April 2018 to April 2019. The study was approved by the Local Ethical Committee of the Faculty of Medicine, Alexandria University. All patients signed a written informed consent to participate in the study and for publication of data before enrollment in the study.
The study included patients of both sexes above 55 years old.
Patients with localized eyelid deformities, scars, defects, previous surgery, entropion, or ectropion (these diseases are attributed to multiple pathologies, only involutional causes apply to the present study) were excluded from the study. In addition, patients with localized eye diseases such as thyroid eye disease, lid infection, blepharoptosis, brow ptosis, and dermatochalasis were also excluded. Patients with systemic diseases such as rheumatoid arthritis, diabetes mellitus, multiple sclerosis, myasthenia, myopathies, and facial palsy were also excluded.
Clinical data were collected from patients including dry eye questionnaire 5 (DEQ 5), demographics (age, sex, and residence), medical history, and ocular irritation history. DEQ 5 is a validated questionnaire consisting of five questions regarding the presence and severity of eye discomfort, dryness, and tearing over a 1-month recall period ([Figure 1]) ,. DEQ 5 scores more than 6 suggest dry eye (DE) and scores more than 12 may indicate further testing to rule out Sjögren’s syndrome DE.
The presence of lower eyelid horizontal laxity was clinically graded by the snapback test. The lower lid was pulled away and down from the globe for several seconds, and we waited to see how long before it returned to the original position without the patient blinking. The test result gives a good idea of relative lower lid laxity. In normal lids, it should spring back into original position immediately; the longer it takes, the more laxity is present:
- Grade 0: normal lid that returns to position immediately on release.
- Grade I: ∼2–3 s.
- Grade II: 4–5 s.
- Grade III: more than 5 s but does return to position with blinking.
- Grade IV: never returns to position and continues to hang down in frank ectropion after the snapback test.
The upper eyelid laxity was determined by the lid distraction test. The lateral aspect of the upper eyelid was pulled superiorly toward the orbital rim:
- Grade 0: indicated laxity within normal limits.
- Grade I: indicated 7–10 mm of distraction.
- Grade 2: indicated greater than 10 mm of distraction.
Medial canthal laxity was tested by the lateral distraction test. The lower lid was pulled laterally away from medial canthus to measure the displacement of the punctum; the greater the distance, the more the laxity. It was graded from 0 to IV (0=normal and IV=severe laxity). Normally, displacement should be only 0–1 mm.
- Grade I: ∼2 mm displacement.
- Grade II: ∼3 mm.
- Grade III: more than 3 mm.
- Grade IV: do not return to baseline.
The lateral canthal laxity was tested by pulling the lower lid medially away from lateral canthus and measuring the displacement of lateral canthal corner; the greater the distance, the more the laxity. Normally, the displacement should be only 0–2 mm (grade 0). It was graded from 0 to IV (0=normal and IV=severe laxity).
- Grade I: 2–4 mm.
- Grade II: 4–6 mm.
- Grade III: more than 6 mm.
- Grade IV: do not return to baseline even after blinking.
The tear film breakup time (TBUT) is a method for determining the stability of the tear film. Sodium fluorescein dye was instilled into the eye, and the tear film was observed under the slit lamp with the use of cobalt blue filter while the patient avoids blinking until tiny dry spots developed. Generally more than 10 s was considered to be normal ,,,,,, whereas 5–10 s is marginal and less than 5 s is considered low. A short TBUT is a sign of a poor tear film, and the longer it takes, the more stable the tear film.
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0 (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level.
Student t test was used for normally distributed quantitative variables, to compare between two studied groups. Mann–Whitney test was used for abnormally distributed quantitative variables, to compare between two studied groups. Kruskal–Wallis test was used for abnormally distributed quantitative variables, to compare between more than two studied groups. Spearman coefficient was used to correlate between two distributed abnormally quantitative variables.
| Results|| |
The study was conducted on 400 patients (799 eyes as one patient had right eviscerated eye) with a mean age of 62.6±6.95 years, with a female predominance (70.3%). It was found that 44% of the patients were from Alexandria, 35.8% from Cairo, and 20.3% from Buhera. The mean score of DEQ was 7.09.
Eyelid laxity prevalence in the right lower and upper eyelids was 51.1 and 14.8%, respectively, whereas in the left lower and upper eyelids, it was 50 and 14.7%, respectively.
Age had a weak positive significant correlation with right lower eyelid laxity and medial canthal tendon (MCT) laxity in both eyes (P=0.010 and P<0.001, respectively, [Table 1]). Otherwise age had insignificant correlation with right upper eyelid laxity and left upper and lower eyelid laxity and lateral canthal tendon (LCT) laxity in both eyes.
The TBUT had insignificant correlation with both sexes ([Table 2]). The TBUT had a weak negative significant correlation with eyelid laxity in the right lower and upper eyelids and in the left lower eyelid (P<0.001), but the left upper eyelid had insignificant correlation with TBUT. In addition, the TBUT had insignificant correlation with MCT and LCT laxity ([Table 3]).
The mean eyelid laxity in the right lower eyelid was 0.75±0.94 in males and 0.74±0.92 in females, with an insignificant difference between them. The mean eyelid laxity in the right upper eyelid was 0.13±0.33 in males and 0.18±0.44 in females, with an insignificant difference between them.
The mean eyelid laxity in the left lower eyelid was 0.69±0.90 in males and 0.78±0.95 in females, with an insignificant difference between them, whereas in left upper eyelid, it was 0.10±0.30 in males and 0.19±0.44 in females, with an insignificant difference between them ([Figure 2]). The mean eyelid laxity in both right and left eyelids had a weak positive significant correlation with age, as it increased with advancing age.
| Discussion|| |
Involutional and chronic eye disorders are of rising importance in the continuum of ophthalmologic diseases because of increasing life expectancy worldwide. They result from the ongoing aging process and genetic origin which cannot be changed by human behavior .
In the current study, we aimed to study the prevalence of eyelid laxity, age as a risk factor for its presence, and its correlation to ocular surface symptoms in an elderly Egyptian population. The mean age of the patients was 62.6±6.95 years, with female predominance (70.3%), and demographic distribution showed that 44% of the patients were from Alexandria, 35.8% from Cairo, and 20.3% from Buhera. The mean DEQ score was 7.09. In the study by Ansari et al. , it was shown that the mean respondent age was 68±13.7 years (range, 25–94 years). Overall, 96% were males, with an average weight of 187.7±38.3 pounds (range, 93–323 pounds).
In the current study, the prevalence of lid laxity in the right lower and upper lids was 51.1 and 14.8%, respectively, and in the left lower and upper lids was 50 and 14.7%, respectively. The high variability of eyelid laxity prevalence in literature may be partially explained by the differences in clinic types. The prevalence of eyelid laxity may be skewed higher in clinics that have patients with more risk factors. In our Egyptian population, with a predominantly female and elderly cohort, the prevalence of laxity may have been high by virtue of having more risk factors for eyelid laxity. However, it was lower than that found in Ansari et al. , who showed that 54% of the participants (n=81) had laxity (grade I or higher) in either the upper and/or lower eyelids. However, all were within the limits of previous estimates, which reported widely variable frequencies of 30 and 88%, respectively ,.
In the present study, there was a positive significant correlation between age and lower lid laxity in the right eye. Also, there was a significant correlation between age and MCT laxity in the right and left eyes, but regarding left lid laxity and LCT lid laxity, there was no significant correlation between them. These findings were similar to those of Chhadva et al. , who found that individuals with eyelid laxity were older (67±10 vs. 55±8 years in individuals without lid laxity, P<0.005).
In addition, there was a negative significant correlation between TBUT and lid laxity in the right lower and upper lids and in the left lower lid, whereas regarding the left upper lid, there was an insignificant correlation. In consistence with our results, Chhadva et al.  found that moreover, patients with eyelid laxity had worse TBUT, corneal staining, Schirmer’s score, Meibomian gland More Details drop out, eyelid vascularity and Meibomian quality compared with patients without eyelid laxity.
In the current study, there were insignificant correlations between TBUT and MCT and LCT laxity. Naderan et al.  found that MCT lateral distraction test, palpebral fissure width, lower eyelid retraction test measurements, and upper eyelid vertical pull were significantly higher in patients with eyelid laxity.
In the present study, there was insignificant correlation between TBUT, in both eyes, and sex. In contrary, Chhadva et al.  found that eyelid laxity was more frequent in males (96 of 127 males; 76% had laxity vs. two of 11 females; 18%; P<0.005).
In the current study, the mean lid laxity in the right lower lids was 0.75±0.94 in males and 0.74±0.92 in females, with an insignificant difference between them, whereas in the right upper lids, it was 0.13±0.33 and 0.18±0.44, respectively, in males and females, with an insignificant difference between both sexes. The left lower lid mean laxity was 0.69±0.90 in males and 0.78±0.95 in females, with an insignificant difference, whereas in the left upper lids, it was 0.10±0.30 and 0.19±0.44, respectively, in males and females, with an insignificant difference. The mean lid laxity had a positive significant correlation with age in both right and left lids, as it increased with advancing age. On the contrary, Naderan et al.  found that age and sex of patients with and without eyelid laxity were not significantly different. This difference in findings was because the sample used in our study was of younger age, with a mean of 62.6 years, whereas the mean age of their study was higher (73.6 years). In addition, there was the ethnicity difference in population samples, as their study was done on keratoconic diabetic patients. This could be explained by the age-related decrease and atrophy of the orbital fat and the relaxation of the ligamentous support, which leads to an increasing eyelid-globe disparity that again compounds the eyelid laxity .
This study has some limitations such as the lower number of included patients. In addition, the cross-sectional design did not allow us to address many unanswered questions regarding eyelid laxity, including its natural history, optimal treatments, and interaction with other signs of DE. All of which warrant further investigation. The study relied on patient-self report of ocular surface symptoms. As such, there may have been variables other than laxity that could have affected the symptoms. Previous authors established criteria that have been used to clinically grade lid laxity based on the presence of papillary conjunctivitis and/or degree of tarsal eversion. There are presently no available guidelines as to the standardization of this entity of lid laxity ,. Therefore, it may be clinician dependent and subject to variability. Additional studies evaluating eyelid laxity in other populations are therefore needed.
| Conclusion|| |
There was a positive significant correlation between age and right lower lid laxity and MCT laxity in both eyes. The eyelid laxity was prevalent in the current population, and its presence was associated with ocular surface morbidity. There was a negative significant correlation between TBUT and lid laxity in the right lower and upper lids and in the left lower lid. The present data suggest that dynamic eyelid testing should be incorporated into the ophthalmic examination in patients with ocular surface discomfort. Relation between OSA and eyelid laxity is recommended to be included in future studies.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Damasceno RW, Avgitidou G, Belfort R, Dantas P, Holbach L, Heindl L. Eyelid aging: pathophysiology and clinical management. Arq Bras Oftalmol 2015; 78:328–331.
Fowler AM, Dutton JJ. Floppy eyelid syndrome as a subset of lax eyelid conditions: relationships and clinical relevance (an ASOPRS thesis). Ophthalmic Plast Reconstr Surg 2010; 26:195–204.
Leibovitch I, Selva D. Floppy eyelid syndrome: clinical features and the association with obstructive sleep apnea. Sleep Med 2006; 7:117–122.
Taban M, Taban M, Perry J. Plasma leptin levels in patients with floppy eyelid syndrome. Ophthalmic Plast Reconstr Surg 2006; 22:375–377.
Chhadva P, McClellan AL, Alabiad CR, Feuer WJ, Batawi H, Galor A. Impact of eyelid laxity on symptoms and signs of dry eye disease. Cornea 2016; 35:531–535.
Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165:1217–1239.
Castori M, Hakim A. Contemporary approach to joint hypermobility and related disorders. Curr Opin Pediatr 2017; 29:640–649.
Grahame R. The multisystemic nature and natural history of joint hypermobility syndrome and Ehlers-Danlos syndrome in children: new research data conflict with widely held views. Rheumatology (Oxford) 2017; 56:2048–2049.
Ammash NM, Sundt TM, Connolly HM. Marfan syndrome-diagnosis and management. Curr Probl Cardiol 2008; 33:7–39.
Demetracopoulos CA, Sponseller PD. Spinal deformities in Marfan syndrome. Orthop Clin North Am 2007; 38:563–572.
Sharif Z, Sharif W. Corneal neovascularization: updates on pathophysiology, investigations & management. Rom J Ophthalmol 2019; 36:15–22.
Sponseller PD, Hobbs W, Riley LH, Pyeritz RE. The thoracolumbar spine in Marfan syndrome. J Bone Joint Surg Am 1995; 77:867–876.
McNab AA. Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea. Clin Exp Ophthalmol 2000; 28:125–126.
Ansari Z, Singh R, Alabiad C, Galor A. Prevalence, risk factors, and morbidity of eye lid laxity in a veteran population. Cornea 2015; 34:32–36.
Karger RA, White WA, Park WC, Rosales AG, McLaren JW, Olson EJ, Woog JJ. Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome. Ophthalmology 2006; 113:1669–1674.
Netland PA, Sugrue SP, Albert DM, Shore JW. Histopathologic features of the floppy eyelid syndrome. Involvement of tarsal elastin. Ophthalmology 1994; 101:174–181.
Naderan M, Jahanrad A, Farjadnia M. Prevalence of eyelid laxity and its association with ophthalmic findings and disease severity in patients with keratoconus. Eur J Ophthalmol 2017; 27:670–674.
Chambe J, Laib S, Hubbard J, Erhardt C, Ruppert E, Schroder C et al.
Floppy eyelid syndrome is associated with obstructive sleep apnoea: a prospective study on 127 patients. J Sleep Res 2012; 21:308–315.
McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthalmic Plast Reconstr Surg 1997; 13:98–114.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]