Examination Methods

The eyelids are examined by direct inspection under a bright light. A slit lamp may be used for this purpose. Bilateral inspection of the eyelids includes the following aspects:

❖ Eyelid position: Normally the margins of the eyelids are in contact with the eyeball and the puncta are submerged in the lacus lacrimalis.

❖ Width of the palpebral fissure: When the eye is open and looking straight ahead, the upper lid should cover the superior margin of the cornea by about 2 mm. Occasionally a thin strip of sclera will be visible between the cornea and the margin of the lower lid. The width of the palpebral fissure is normally 6-10 mm, and the distance between the lateral and medial angles of the eye is 28-30 mm (Fig. 2.2). Varying widths of the gaps between the eyelids may be a sign of protrusion of the eyeball, enophthal-mos, or eyeballs of varying size (Table 2.1).

❖ Skin of the eyelid: The skin of the eyelid is thin with only a slight amount of subcutaneous fatty tissue. Allergic reaction and inflammation can rapidly cause extensive edema and swelling. In older patients, the skin of the upper eyelid may become increasingly flaccid (cutis laxa senilis). Occasionally it can even hang down over the eyelashes and restrict the field of vision (dermatochalasis or blepharochalasis).

— Dimensions of the normal palpebral fissure. -

9 mm

— Dimensions of the normal palpebral fissure. -

{ 3 mm

width of the palpebral fissure is an important indicator for a number of pathologic changes in the eye (see Table 2.1).

28-30 mm

20 2 The Eyelids Table 2.1 Possible causes of abnormal width of the palpebral fissure

Increased palpebral fissure Decreased palpebral fissure

Peripheral facial paresis (lagophthalmos) Grave's disease Perinaud's syndrome Buphthalmos High-grade myopia Retrobulbar tumor

Congenital ptosis

Ptosis in oculomotor nerve palsy

Ptosis in myasthenia gravis

Sympathetic ptosis (with Horner's syndrome, see pp. 23-24)

Progressive ophthalmoplegia (Graefe's sign)



Shrinkage of the orbital fat (as in senile enophthalmos)

The palpebral conjunctiva is examined by simple eversion of the upper eyelid (see Figs. 1.7 and 1.8). The normal palpebral conjunctiva is smooth and shiny without any scar strictures or papilliform projections.

Full eversion of the upper eyelid with a Desmarres eyelid retractor (see Fig. 1.9, p. 9) allows examination of the superior fornix (for normal appearance, see palpebral conjunctiva).

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