Sudden pseudoproptosis.

A 52-year-old man with no previous medical history, but a high body mass index (BMI) >34, presented with a sudden onset of a painful, apparently proptosed left eye and decreased left vision (see figure 1). He had rubbed his eye on waking. On examination, there was no relative afferent pupillary defect. Snellen chart testing was 6/12 (pinhole 6/6) ocular sinistra (OS) and 6/6 ocular dextra (OD). Exophthalmometry demonstrated no evident proptosis objectively. A CT scan confirmed no proptosis and no other ocular, orbital or intracranial pathology. The left eye had punctate, corneal erosions and a hyperaemic conjunctiva. There was no evidence of intraocular inflammation and funduscopy was unremarkable. Pseudoproptosis caused by floppy eyelid syndrome was diagnosed and the lids were repositioned. Corneal prophylaxis, topical chloramphenicol 4 times per day (QDS), was prescribed. Floppy eyelid syndrome is described in overweight middle-aged men. It is a disorder of unknown origin manifested by an easily everted, floppy upper eyelid and upper palpebral conjunctivitis. The upper eyelid everts during sleep, resulting in irritation, conjunctivitis and conjunctival keratinisation. Causes of pseudoproptosis include high myopia, buphthalmos, contralateral enophthalmos, asymmetric orbital size (congenital, postirradiation, surgery) and asymmetric palpebral fissures (ipsilateral eyelid retraction, scarring, facial nerve paralysis or contralateral ptosis).