The corneal findings in 60 patients with floppy eyelid syndrome seen at the Bascom Palmer Eye Institute over a 10-year period were determined by review of their medical records. Punctate epithelial keratopathy (45%), and both clinical (10%) and subclinical keratoconus were the most commonly encountered corneal disorders. Two patients developed progressive endotheliopathy (Chandler's syndrome and nonguttate endothelial dystrophy) during the period of observation. In contrast to previous reports in which almost all patients were obese men, 37% (n=22) of our patients were women and only 29% of all patients were obese. All patients slept face down, usually on the most severely affected eye. Treatment by lid shortening surgery and/or an eye shield provided symptomatic relief. A pathogenetic theory is advanced that the degenerative changes in the tarsus result from the combination of local pressure-induced lid ischemia and systemic hypoventilation followed by reperfusion oxidation injury.