Periocular Manifestation of Obstructive Sleep Apnea as a Novel Perioperative Screening Tool

Megan Folsom, James Gigantelli, Brent Timperley, Kurtis Johnson, Danstan Bagenda, Huiling Pang, Sheila Ellis

Research output: Contribution to journalArticlepeer-review


Purpose: Obstructive sleep apnea (OSA) presents perioperative challenges with increased risk for complications. Floppy eyelid syndrome (FES) is associated with OSA yet has not been addressed perioperatively. The current standard for perioperative OSA screening includes assessing patient risk factors or the STOP-BANG tool, which requires an active participant. We aimed to confirm a connection between FES and OSA in presurgical patients and develop a screening method appropriate for patients with perioperative OSA risk. Materials and Methods: 162 presurgical pre-anesthesia clinic patients were enrolled. Screening questions determined eligibility. Those who were pregnant or aged < 19 were excluded. Control group included those with a STOP-BANG score < 3. Experimental group included those with BMI > 35 and OSA diagnosis. Examiners photographed participants’ eyes with vertical and horizontal retraction while two blinded ophthalmologists used a grading scale to review grade of eyelid laxity. Results: Differences in habitus, ASA score, and hypertension as a comorbidity were significant. Sensitivity of FES screening was 52% (CI 37–66%) and specificity was 56% (CI 46–66%) for reviewer 1. For reviewer 2, sensitivity was 48% (CI 28–69%) and specificity was 72% (CI 60–81%). Negative predictive value was 86% (CI 81–90) for reviewer 1 and 88% (CI 83–92%) for reviewer 2. Inter-rater agreement was moderate. Conclusion: While specificity and sensitivity were lower than anticipated, negative predictive value was high. Given this strong negative predictive value, our findings indicate using eyelid retraction to screen for FES has perioperative clinical utility. These findings encourage further research addressing the connection of lid laxity/FES to OSA. Key Points: • Aimed to investigate if a FES screening tool could identify perioperative OSA risk. • Negative predictive value for FES with OSA was 86%. • Observing periocular lid laxity has clinical utility; is feasible in any patient. Graphical abstract: [Figure not available: see fulltext.]

Original languageEnglish (US)
Pages (from-to)1103-1109
Number of pages7
JournalObesity Surgery
Issue number4
StatePublished - Apr 2022


  • Eyelid laxity
  • Floppy eyelid syndrome
  • Obstructive sleep apnea
  • Perioperative medicine
  • Preoperative assessment
  • Screening tool

ASJC Scopus subject areas

  • Surgery
  • Endocrinology, Diabetes and Metabolism
  • Nutrition and Dietetics


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