Lid Imbrication Syndrome

Lid imbrication syndrome refers to abnormality of lid apposition in which upper eyelid overrides the lower eyelid. This causes lower eyelid lashes and keratinised epithelium to rub chronically against the upper eyelid marginal tarsal conjunctiva. This leads to keratinisation of the upper eyelid margin and metaplasia of the distal tarsal conjunctiva. The resulting abnormal distal superior palpebral surface, in turn, irritates the underlying corneal surface on blinking and prohibits normal replenishment of the tear film. There are symptoms of dryness due to poor tear film being produced by disruption in tear film mechanics. It may lead to persistent corneal epithelial defects.

This condition as a cause of chronic conjunctivitis was initially described by Karesh and others (1993). This disorder may have some overlap with floppy eyelid syndrome.

Because the upper eyelid overlies the lower eyelid, visualisation of eyelid apposition during closure of eyes may be difficult, and hence, this disorder may be missed. Many patients may be misdiagnosed as a case of keratoconjunctivitis sicca (dry eye syndrome).



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Holland Edward J, Mannis Mark J, Lee W. Barry. Ocular Surface Diseases- Cornea, Conjunctiva, and Tear Film. Elsevier Saunders 2013. P 36.

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Bowling Brad, Kanski's Clinical Ophthalmology- A Systematic Approach. Eighth Edition. Elsevier, 2016. P 55.

Sundaram Venki, Barsam Allon, Alwitry Amar, Khaw Peng T. Training in Ophthalmology- the essential clinical curriculum. Oxford University Press 2009. P 98.;year=2013;volume=61;issue=10;spage=593;epage=596;aulast=Chandravanshi

Karesh JW, Nirankari VS, Hameroff SB. Eyelid inmrication. An unrecognised cause of chronic ocular irritation. Ophthalmology 1993; 100: 883- 889.

Lid imbrication syndrome may present with symptoms such as

  • Irritation of eyes.
  • Foreign body sensation.
  • Burning of eyes.
  • Symptoms of dryness of eyes.
  • Persistent corneal epithelial defects.
  • Overriding upper eyelid on the lower eyelid.


Lid imbrication syndrome is an idiopathic eyelid mal-position disorder and is characterized by upper eyelid overriding the lower eyelid.

Lid imbrication syndrome may be seen as

  • Acquired condition: When acquired, it is commonly associated with floppy eyelid syndrome.
  • Congenital condition: Congenital occurrence is very rare.
  • Post-surgical condition: Occasionally, it may follow lower eyelid tarsal strip surgery.

Closure of the eyelids is primarily is a function of the upper eyelid, with the lower lid exhibiting very little upward movement during closure of the eyes. As a result, many patients tolerate lower eyelid retraction with minimal symptoms, if the upper lid function is normal.

Lid imbrication syndrome causes ocular surface problems through the mechanical rubbing of eyelashes against the conjunctival and corneal surfaces. It is not only the trauma of the eyelashes rubbing, but also the induced chronic low grade inflammation which contributes. It further exacerbates the disease process.

Diagnosis of lid imbrication syndrome is primarily clinical.

On physical examination of the eyes, the condition is best evaluated by having the patient tilt head back and then observing from beneath with a penlight whether the upper eyelid overrides the lower or not. Many patients have gelatinous thickening of the upper eyelid tarsal marginal conjunctiva.

Vital staining: Topical rose bengal or lissamine green staining may be used to diagnose lid imbrications. These stain the tarsal conjunctiva along the upper eyelid margin. The severity of staining correlates to the severity of symptoms.

In addition to upper eyelid laxity, some patients have concomitant lower eyelid laxity without ectropion.


Differential diagnosis

Lid imbrication syndrome should be differentiated from

  • Floppy eyelid syndrome: Patients with lid imbrication syndrome alone show no predisposition to eyelid eversion and lack the rubbery, easily distensible upper eyelid tarsal plate. These patients also do not demonstrate upper tarsal giant papillary conjunctivitis. Moreover, the eyelid abnormalities are confined to the lid marginal tarsal conjunctiva. Furthermore, lid imbrication syndrome is more common in females.

However, lid imbrication syndrome has some overlap with the floppy eyelid syndrome.

Management should be carried out under medical supervision.

Medical management to stabilise the ocular surface and reduce inflammation is required, but often it is important to surgically address the abnormal eyelid position.

Medical therapy

  • Artificial tears: Initial management consists of lubrication with artificial tears.


Surgical therapy

  • Horizontal tightening of upper eyelid: Horizontal tightening of upper eyelid to prevent upper tarsal and lower eyelid apposition may be tried.
  • Temporary tarsorrhaphy: Patients with persistent corneal epithelial defects due to lid imbrication syndrome may require temporary tarsorrhaphy to prevent the upper eyelid from overriding the lower eyelid.

Lower eyelid may be tightened, if it is also lax.

  • PUBLISHED DATE : Mar 28, 2017
  • CREATED / VALIDATED BY : Dr. S. C. Gupta
  • LAST UPDATED ON : Mar 28, 2017


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