Basic Examination of Oculoplasty Booklet 2

v Gunjan Saluja v Neelam Pushker
v Sahil Agarwal v M.S Bajaj

DOS Office Bearers

Dr. Subhash C Dadeya Dr. Pawan Goyal Dr. Namrata Sharma Dr. Hardeep Singh
President Vice President Secretary Joint Secretary

Dr. Jatinder S Bhalla Dr. Vinod Kumar Dr. Manav Deep Singh
Treasurer Editor Library Officer

Executive Members

Dr. Dewang Angmo Dr. Jatinder Bali Dr. Shantanu Gupta Dr. C. P. Khandelwal

Dr. Rahul Mayor Dr. Vipul Nayar Dr. Rajendra Prasad Dr. Kirti Singh

DOS Representative to AIOS Ex-Officio Members

Dr. Jeewan S. Titiyal Dr. M. Vanathi Dr. Rakesh Mahajan Dr. Arun Baweja

Basic
Examination of

Oculoplasty

Foreword

Respected Seniors and Dear Friends

Oculoplasty is an important sub-specialty

of ophthalmology. It is very common to

encounter patients with disorders involving

the eyelids, orbit, and ocular adnexa in an

ophthalmic outpatient department. These

disorders not only cause cosmetic blemish as

well as have pschyo-social implications, hence Prof. (Dr.) Namrata Sharma
timely diagnosis is the key. The understanding
Hony. General Secretary

of various oculoplasty disorders has greatly

increased with time, both in terms of etiopathogenesis and management

options. Imaging modalities though help to reach a definite diagnosis,

a good clinical examination cannot be replaced. This special issue on

“Basic Examination of Oculoplasty cases” focuses on the examination

of common oculoplasty disorders, like ptosis, proptosis, contracted

socket, lid tumors, and ectropion and entropion. Various aspects of

examination beginning from history taking to specific tests for each

disorder have been covered in a sequential manner.

This will help the newly joined residents, to gain confidence while
examining patients both in the out-patient as well as inpatient
department.

We look forward to better understanding and learning of the
oculoplasty disorders, thus creating good clinicians.

Prof. (Dr.) Namrata Sharma

Hony. General Secretary, DOS

ii | Basic Examination of Oculoplasty

Ptosis Evaluation

Ptosis is a common condition presenting in the oculoplasty clinic
and is defined as drooping of the upper eyelid.

Relevant history in ptosis

History taking is of utmost importance in a patient with ptosis. The
relevant history taking points in a patient with ptosis include:

Onset, progression, and duration: Onset since birth indicates the
diagnosis of congenital ptosis. The progressive ptosis can be associated
with chronic progressive external ophthalmoplegia and myasthenia
gravis.

Diurnal variation
History of diurnal variation should not be missed. It is an important
complaint in the patients of myasthenia gravis. 50% patients of ocular
myasthenia gravis can present primarily with diplopia and ptosis
as the first presenting symptom.1 The characteristic history is the
improvement of ptosis after rest with its worsening towards evening
hours.

History of trauma
Trauma can cause disinsertion, and dehiscence of the levator
aponeurosis leading to aponeurotic ptosis. Post-traumatic third
nerve palsy can also lead to severe ptosis with diplopia and limited
extraocular movements.

History of previous ocular surgery
Ptosis can occur after cataract surgery, the reported incidence has

Basic Examination of Oculoplasty | 1

been as high as 13%.2 It has been proposed that ptosis can occur by
the opposing forces created by the lid speculum. The superior rectus
bridle suture can also cause levator aponeurosis dehiscence because of
the strong fascial attachments between the superior rectus and levator
muscle.3

Family history
Family history can be positive in patients with chronic progressive
external ophthalmoplegia, Kearns Sayre syndrome (mitochondrial
inheritance), and blepharo-phimosis ptosis epicanthus inversus
syndrome, BPES (autosomal dominant inheritance).

History of contact lens use
Contact lens use can cause giant papilla leading to mechanical ptosis.
Contact lens use can also lead to aponeurotic ptosis by the micro-
trauma caused during the insertion and removal of contact lenses.

Clinical Examination of a case of ptosis

The examination of ptosis can be subdivided into two heads
1. Examination to diagnose the underlying etiology
2. Examination for the surgical planning

Besides this, uniocular visual acuity documentation, refraction,
anterior segment examination and fundus examination must be
performed in each case.

Before beginning the examination of ptosis it is important to
differentiate between ptosis and pseudoptosis.

Pseudoptosis
Pseudoptosis includes the conditions which simulate ptosis but the
droop is not a result of levator malfunction.

Monocular elevation deficit with hypotropia, and enophthalmos, are
the common causes of pseudoptosis.

Pseudoptosis and hypotropia
Ptosis can be associated with hypotropia because of the fascial

2 | Basic Examination of Oculoplasty

attachments between levator palpebrae superioris, and superior
rectus muscle. Pseudoptosis disappears when hypotropic eye takes
up fixation in primary position. Surgical correction for ptosis is not
required in these patients as the pseudoptosis gets corrected by the
vertical alignment of the globe alone.(Figure1)

Figure 1: Pseudoptosis associated with hypotropia

1. Examination to diagnose the underlying
etiology

Facial features: Typical facial features are associated with Blepharo-
phimosis ptosis, and epicanthus inversus syndrome (Figure 2).

The typical features
include narrowing of
horizontal palpebral
aperture, severe pto-
sis, epicanthus inver-
sus, and telecanthus.

Other features include Figure 2: Facial features of a patient with BPES
a high arched eye- syndrome. Blepharo phimosis, ptosis, and epicanthus
brow, flat forehead,
flat nasal bridge, inversus syndrome
flat maxilla, and cup
shaped ears.

Basic Examination of Oculoplasty | 3

Head posture

A chin-up head posture is associated with severe ptosis and is a
compensatory mechanism to clear the visual axis, thus preventing
visual deprivation amblyopia.

Lid crease, lid fold and margin crease distance

A lid crease is formed

by the insertion of

fibers of levator

aponeurosis and the

distance between

the upper lid margin

and lid crease is

the marginal crease

distance. In normal

individuals, the

marginal crease

distance is 8-9 mm in Figure 3: A patient of congenital ptosis with absence of
males and 9-11 mm in
lid fold and lid crease

females. However, in

patients with aponeurotic ptosis, the marginal crease distance will

be increased as the lid crease is elevated and in congenital ptosis as

the levator muscle, is replaced by fibro-fatty tissue leading to the

disappearance of the lid crease. (Figure 3)

Lid lag

Presence of lid lag

is an important

sign to differentiate

congenital and

acquired ptosis.

In lid lag, the upper Figure 4: A congenital ptosis patient with lid lag
lid lags and lies at a
higher level as the
patient looks down.

In patients with congenital ptosis due to fibro-fatty infiltration of

4 | Basic Examination of Oculoplasty

LPS, the muscle cannot contract or relax, resulting in lid lag. (Figure
4)

Iliff Test
The ptosis in an uncooperative child can be examined by this test.
upper eyelid is everted as the child looks down. If the levator action
is good the lid reverts on its own.

Ptosis in Myasthenia gravis
Suspect myasthenia gravis when the patient has:

1. Diurnal variation of symptoms, or variable position of eyelids
during examination

2. Ptosis associated with diplopia, and limitation of extraocular
movements such that the pattern does not follow any particular
cranial nerve palsy.

The important signs for myasthenia gravis include

Cogan lid twitch sign
To demonstrate the Cogan lid twitch sign, the patient is asked to look
in the downgaze for 15 sec, and a small upshot of the eyelid can be
noted as the eyelids move back to the primary position.

Peek sign
The examiner tries to open the lids when the patient holds them shut.
This test is done for the orbicularis oculi muscle. In patients with
myasthenia gravis, one or both eyes of the patient may open and the
patient appears to peek at the examiner.

Commonly performed bedside test are:

Ice Pack test
A clinical photograph of the patient is taken before the test, and an ice
pack is kept in the upper lid for 3- 5 minutes, and the improvement
in ptosis can be noted. A post-test clinical picture can then be used to
compare the same. An improvement in the palpebral fissure height of
more than 2mm is considered to be significant.

Basic Examination of Oculoplasty | 5

5a 5b
Figure 5: 5a Pre and post 5b ice pack test pictures of a patient with suspected
myasthenia gravis

Cooling is believed to reduce anticholinesterase activity, thus increases
the amount of available acetyl choline at the neuro-muscular junction.

Fatigue test
MRD1 is measured before the test, the patient is then asked to have
a sustained look in the upgaze for about 1 min. to induce fatigue.
MRD1 is measured again after the test. An increase in MRD1 value is
observed after the test in patients with myasthenia.

Neurogenic ptosis
Neurogenic ptosis can result from third nerve palsy, or as a component
of Horner’s syndrome due to palsy of Muller’s muscle.

Third nerve palsy
Third nerve palsy presents with limitation of adduction (medial
rectus), elevation (superior rectus), depression (inferior rectus and
inferior oblique palsy). Pupil in the case of third nerve palsy can be
fixed and dilated with the presence of anisocoria.

Horner’s syndrome
Horner’s syndrome is characterized by the presence of ptosis, miosis,
enophthalmos, anhydrosis, and loss of cliniospinal reflex.

Ciliospinal reflex, also known as pupillary skin reflex. Dilation of
ipsilateral pupil is observed in response to pain applied to neck or face.

However, the reflex is absent in Horner’s syndrome.

6 | Basic Examination of Oculoplasty

Congenital Horner’s syndrome can also have a component of
heterochromia iridis. Ptosis in a case of Horner’s syndrome is usually
mild and can be confirmed by a simple bedside, 2.5% phenylephrine
test, or amphetamine test. The syndrome can result from damage
anywhere along the sympathetic pathway, which can be divided
by first order neurons (hypothalamus to spinal cord), second order
neurons (spinal cord to superior cervical ganglion) and third order
neuron (superior cervical ganglion to orbit).

It is important to determine which order neuron is involved because
Horner’s syndrome secondary to involvement of the first or second
order neurons may be caused by underlying malignancy.

The diagnosis of Horner’s syndrome is confirmed if apraclonidine
drop testing results in reversal of anisocoria Hydroxyamphetamine
test helps to localize the level of dysfunction. Pupillary dilation by
amphetamine drops is present if the dysfunction is at the level of the
first or second order neurons, while no dilation occurs if the third order
neuron is affected.

Phenylephrine test
Phenylephrine is instilled in the upper fornix. Phenylephrine stimulates
the alpha receptors, causing the contraction of Muller’s muscle and lid
elevation.

Evaluation for surgical planning
The foremost examination before beginning the surgical planning of
ptosis is to see the Bell’s phenomenon and corneal status.

Bell’s phenomenon
Bell’s phenomenon is the upward and outward movement of the eye
when the attempt is made to close the eyes. (Figure 6)

Demonstration of Bell’s phenomenon
The patient is asked to gently close his eyes, and the examiner holds
the lids open. If the eyes move up, with less than 1/3rd of the cornea
being visible, indicates good Bell’s phenomenon.

Basic Examination of Oculoplasty | 7

Figure 6: Bell’s phenomenon demonstration in a ptosis patient

Grading of Bell’s phenomenon
• Good-less than 1/3 cornea visible
• Fair- 1/3 to ½ of cornea visible
• Poor- > ½ cornea visible
• Reverse- upward and inward
• Inverse- downward and inward
Ptosis surgery is never performed in patients with poor Bell’s due to
their higher risk of develop exposure keratopathy.

Corneal sensations
Corneal sensations can be tested using a wisp of cotton, the patient
is approached from the side, away from the line of vision. The cotton
wisp gently touches the cornea and blinking is observed.

Quantitative measurement of the corneal sensations can be doneusing
esthesiometer.

Ptosis surgery is avoided in patients with reduced or absent corneal
sensations, and in patients with any other corneal pathology, as they
are at a higher risk of developing exposure keratopathy and persistent
epithelial defects.

8 | Basic Examination of Oculoplasty

Test for Dry eye
Ptosis surgery can further worsen the dry eyes.4 Hence, evaluation
for dry eyes remains an essential element when planning for ptosis
surgery.

1. Schirmer’s test
Schirmer’s strips are prepared using Whatman filter paper # 41,

in a dimension of 5mm by 35 mm, a tab of 5mm at one end
of the strip is to be folded. Markings are made at a distance of
5mm beginning below the tab from 5mm to 35 mm and can also
labeled right and left for the ease of use. The folded tip is inserted
into the lower lid – at the junction of the middle and outer thirds
of the lower lid – taking care not to touch the cornea or lashes.
The patient is asked to keep their eyes closed for the duration
of the test. After 5 minutes, the filter paper is removed and the
amount of wetting from the fold is measured. Measurement of
>15mm after 5 minutes is normal.

2. Tear film break uptime (TBUT)
To measure TBUT, fluorescein is instilled into the patient’s tear

film and the patient is asked not to blink while the tear film is
observed under a broad beam of cobalt blue illumination. The
TBUT is recorded as the time elapse between the last blink and
the appearance of the first dry spot in the tear film.

Normal tear film break up time is 10 seconds, 5-10 seconds is the
marginal and less than 5 seconds is considered to be low.

Frontalis overaction
Frontalis overaction is an attempt made by the patient to elevate the
upper eyelid and is seen in patients with severe ptosis. The frontalis
over-action can be made use of, and the frontalis sling procedure can
be planned in these patients.

Compensatory lid retraction
Compensatory lid retraction can be seen in patients of unilateral ptosis,
and is explained by the Herring’s law of equal innervation. To elevate
the ptotic lid, an increased innervation is received to the normal side

Basic Examination of Oculoplasty | 9

Measurements in ptosis
Frontalis action must be blocked before performing any measurement
in ptosis
Marginal reflex distance
Marginal reflex distance 1
MRD1 is the distance between the upper lid and the pupillary reflex.
Normally the upper lid cover 1/6th of the cornea and MRD1 measure
4-4.5mm. (Figure 7)

\\

Figure 7: Marginal reflex distance measurement

The MRD1 is measured by asking the patient to look straight into the
torchlight and after blocking the frontalis muscle the distance between
the central pupillary reflex and upper lid margin is measured by using
a transparent plastic ruler.
Similarly, for MRD2 the distance between central pupillary reflex and
lower lid margin is measured. Normal MRD 2 is 5-5.5mm.
Marginal reflex distance 3 (MRD3)
MRD3 is the distance between the central light reflex and the upper lid
margin, with the patient looking in extreme upgaze.
Amount of ptosis
In cases with unilateral ptosis, the difference of MRD1 between the
two eyes gives the amount of ptosis. Accordingly, ptosis can be graded
as

10 | Basic Examination of Oculoplasty

Mild 2mm
Moderate 3mm
Severe > 4mm

In uncooperative children and a busy OPD setting one can simply
estimate the amount of ptosis by looking at the distance between the
pupillary reflex and lid margin. After blocking the frontalis over-
action if the lid completely covers the pupil, it suggests severe ptosis.
In mild cases, the upper lid margin just touches the pupillary border
and in moderate cases, the upper lid lies in the mid-way of pupillary
reflex. (Figure 8)

MRD c

a

bd

Figure 8: Amount of ptosis based on the pupillary reflex

LPS action
LPS action is assessed by the amount of distance traveled by the lid as
the patient looks from downgaze to upgaze. (Figure 9)

The patient and the examiner must be at the same level, and patient’s
head must be stabilized. A scale is placed and thumb is placed on
the forehead to block the action of frontalis muscle. After blocking
the frontalis the patient is asked to look down and is then asked to
look up, the distance traveled is the amount of LPS action and can be
graded as
Good 12-14mm
Fair- 5-11mm
Poor <4mm

Basic Examination of Oculoplasty | 11

Figure9: Measurement of LPS excursion
Marcus Gunn Jaw Winking Phenomenon(MGJWP)
MGJW is a synkinetic movement of the upper eyelid on the movement
of the jaw in congenital ptosis resulting from an aberrant innervation
between the motor division of trigeminal nerve controlling the lateral
pterygoid muscle responsible for masticating movement of jaw and
motor division of oculomotor nerve supplying levator palpebrae
superioris. Thus, causing an eyelid elevation on mastication, or on
contralateral movement of lower jaw. MGJW is graded based on the
amount of eyelid elevation as:
Mild ≤2mm
Moderate 2-5 mm
Severe > 5 mm5
Reinforcement test in MGJWP
Maximum lift of upper eyelid in a patient with MGJWP can be assessed
by applying resistance in opposite direction of jaw movement.

Figure 10: Marcus Gunn Jaw Winking phenomenon (Picture credits: Deep Sekhar
Das, Senior Resident, RP Centre, AIIMS)

12 | Basic Examination of Oculoplasty

Figure 11: Lagophthalmos in a patient with congenital ptosis

References

1. Grob D, Arsura EL, Brunner NG, Namba T. The course of myasthenia gravis
and therapies affecting outcome. Ann N Y Acad Sci. 1987;505:472-99.

2. Alpar JJ. Acquired ptosis following cataract and glaucoma surgery. Glaucoma
1982;466-68.

3. Singh SK, Sekhar GC, Gupta S. Etiology of ptosis after cataract surgery.
J Cataract Refract Surg. 1997 Nov;23(9):1409-13. doi: 10.1016/s0886-
3350(97)80124-1.

4. Bagheri A, Najmi H, Salim RE, Yazdani S. Tear condition following unilateral
ptosis surgery. Orbit. 2015 Apr;34(2):66-71.

5. Bowyer JD, Sullivan TJ. Management of Marcus Gunn jaw winking synkinesis.
Ophthalmic Plast Reconstr Surg. 2004 Mar;20(2):92-8.

Basic Examination of Oculoplasty | 13

Examination of a case
of Contracted Socket

History

A contracted socket can result either after enucleation or evisceration
surgery, or can also be resent in congenital anophthalmia. If the patient
had acquired anophthalmos the records of previous surgery in terms
of size of implant placed must be noted, as it helps in further surgical
planning

Figure 1: A patient after enucleation with a well-fitting prosthesis

History of previous surgeries for contracted socket should be recorded.
A patient of contracted socket usually presents with complaints of an
ill-fitting prosthesis, with a poor cosmetic appearance and repeated
extrusion of the prosthesis. (Figure 2)

Patients with a previous

history of radiation,

trauma, cicatricial

diseases of the

conjunctiva, mutilating

ocular trauma, and

chronic inflammation are

predisposed to develop Figure 2: A patient with an ill-fitting prosthesis,
ptosis, and a deep superior sulcus
contracted socket.

14 | Basic Examination of Oculoplasty

Examination of a case of contracted socket

Eyelid
Eyelids should be examined for eyelid notches, contour abnormalities,
sagging of lower lid, shortening of palpebral aperture, stretching, and
lengthening of the lower lid. The lids should also be examined for
ectropion laxity, ectropion and entropion which can indicate socket
contracture. The presence of ptosis with deep superior sulcus indicates
volume loss. Shelving of inferior fornix can lead to ectropion of lower
eye lid.

Assessment of the socket
The horizontal and vertical dimensions of the lid aperture should be
measured. Normally the horizontal dimension is 28-30 mm and the
vertical dimension is 8-10 mm.

Volume of socket: To assess the volume of the socket patient is made
to lie down in a supine position, and saline is instilled drop by drop
till it overflows. The amount of saline needed to fill the socket till it
overflows shows the volume of the socket.

Depth of fornices: The depth of fornices can be measured by using
a lacrimal probe. A Bowman’s lacrimal probe is inserted into each
fornix, with the patient looking in the respective direction. The length
up to which the probe can
pass is noted. Normal
depth:

Inferior fornix 8-10mm
Superior fornix;10-12mm
Medial fornix is 1-2mm
Lateral fornix 2-3mm

The inferior fornix is
the most important as it
supports the prosthesis.
(Figure 3)

Surface of socket: The Figure 3: Measurement of the depth of fornix

Basic Examination of Oculoplasty | 15

surface of the socket
must be carefully
examined. A normal
socket is lined by
the healthy wet pink
conjunctival mucosa.
There should not be
any active discharge in
the socket. Dry fibrotic
conjunctiva indicates
a poorly vascularized
socket. The socket
bed should also be Figure 4: A wet socket surface
examined to look for
pyogenic granuloma which can be a cause of recurrent bleeding for the
socket bed. Severe scarring can also lead to the formation of cicatricial
bands. (Figure 4)

Socket palpation: Palpation of the socket bed should be done to
palpate the implant and mass and for recurrence of the tumor.

Prosthesis: The prosthesis should be checked for ragged irregular
margins and irregular surface which can lead to chronic irritation, and
papillary conjunctivitis.

Orbital rim: The horizontal and vertical dimensions of orbital rim must
be measured. The normal horizontal orbital diameter is 36-38 mm and
the normal vertical diameter is 37-39mm. Orbital rim is palpated to
look for any bony irregularity and discontinuity of rim.1

Periorbital area: Periorbital area must be inspected to look for scarring,
lateral and medial canthal dystopia. facial and brow asymmetry.

References

1. Gupta V, Prabhakar A, Yadav M, Khandelwal N. Computed tomography
imaging-based normative orbital measurement in Indian population. Indian J
Ophthalmol. 2019;67(5):659-663. doi:10.4103/ijo.IJO_1187_18

16 | Basic Examination of Oculoplasty

Examination of a Case
of Proptosis

Proptosis is defined as a forward (anterior) movement of the globe
in relation to the skull and is measured by the protrusion of the apex
of the cornea in front of the outer orbital rim. A difference of >2 mm
between two eyes is abnormal. Exophthalmos is defined as those cases
which are secondary to endocrinological disorders.

Axial proptosis

The displacement of the eye in the forward and anteroposterior axis
causes axial proptosis. Axial proptosis is usually associated with
intraconal tumors and as exophthalmos in patients with thyroid eye
disease.

Abaxial proptosis

In abaxial proptosis, the eye is pushed forward as well as off the
central axis.

History

1) Age
The cause of proptosis in various age-groups varies. The etiologies

of proptosis in different age groups have been summarized in
Table 1.
2) Nature of onset
Sudden onset (hours to days) suggests an infective and
inflammatory process, trauma associated with orbital fracture and
emphysema.
Gradual onset over several months to years suggests benign
lesions and lymphoproliferative disorders.

Basic Examination of Oculoplasty | 17

Tabe1: Causes of proptosis in various age groups

Newborn Children Young Middle age Senile
adults
Teratoma Veno-lymphatic Thyroid oph- Malignant
Meningo- malformation Thyroid thalmopathy and met-
cele Rhabdomyosar- ophthal- Cavernous astat- ic
Encepha- coma mopathy haemangioma tumours of
locele Leukemia Tuberculosis orbit
Dermoid Capillary Idiopathic Granuloma- Pseudo-
cyst hemangioma orbital in- tous disease tu-
Orbital Dermoid cyst flammatory Idiopathic mour
cellulitis Orbital cellulitis disease orbital inflam- Leukemias
Optic nerve gli- matory disease and lym-
oma Orbital Pleomorphic pho- mas
cellulitis adenoma Sarcomas
Dermoid Lymphomas/
cyst leukemias
Osteomas Optic nerve
Infiltrative sheath menin-
tumours giomas
Mucocoele

3) Progression

Gradual painless progressive lesions are usually benign in nature,
on the contrary, the malignant pathologies, inflammation, and
hemorrhage are rapidly progressive lesions.

An intermittently increasing proptosis can be associated with
repeated attacks of common cold/ upper respiratory tract infections
in lymphatic malformations, similarly, a postural increase of
proptosis with Valsalva or bending forwards is associated in
patients with orbital varices.

4) Unilateral/ bilateral proptosis

The causes of unilateral and bilateral proptosis have been
summarized in table 2.

18 | Basic Examination of Oculoplasty

Table 2: Causes of bilateral proptosis Neoplasia Lymphoma
Leukemia
Inflammations Metastatic carcinoma
Thyroid orbitopathy Optic nerve glioma
Wegener’s granulomatosis Ethmoidal mucocele
Idiopathic inflammatory orbital disease Midline neoplasia
Myositis
Sarcoidosis Vascular Lesions
Sjögren’s syndrome Arteriovenous shunts
IgG4 orbitopathy Varix

Structural Lesions
Craniofacial dysostosis
Dacryops

5) Associated symptoms

Vision loss is associated with either compressive optic neuropathy
due to the orbital mass or can be due to the intrinsic mass arising
from the optic nerve such as optic nerve glioma.

Induced astigmatism by the underlying retro-orbital mass lesion
and exposure keratopathy may cause of vision.

Pain, swelling, redness of the overlying skin usually suggests an
infectious and inflammatory pathology. Pain can also be associated
with malignant tumors having a perineural spread as in patients of
adenoid cystic carcinoma of the lacrimal gland.

6) Systemic history- A history of thyroid disorder is associated with
thyroid-associated ophthalmopathy. Sarcoidosis can be associated
with the orbital inflammatory disorder.

7) Past history –trauma, malignancy, periorbital surgery

Examination of Proptosis

Subjective assessment of proptosis can be done by

Naffziger’s method
Relative protrusion of the eyes can be observed by standing behind
a seated patient, and gazing downwards tangentially towards the chin

Basic Examination of Oculoplasty | 19

from the forehead to assess the relative protrusion of the eye beyond
the orbital rim.
Worm’s eye view
Worm’s eye view is similar to Naffziger’s method but here the examiner
examines up from below with the patient’s head tilted back. (Figure 1)

Figure 1: Worm’s eye view

Facial asymmetry and the shape of the skull are important to look for
craniosynostosis which can lead to pseudo-proptosis due to shallow
orbits, exorbitism. (Figure 2)

Figure 2: Craniosynostosis with pseudo-proptosis
20 | Basic Examination of Oculoplasty

Direction of proptosis
Axial proptosis as described is the protrusion of the eyes in the
anteroposterior axis and is associated with intraconal tumors and
thyroid eye disease. (Figure 3)

Figure 3: Axial proptosis in a patient with cavernous haemangioma Abaxial
proptosis

Abaxial proptosis
The direction of globe dystopia helps in determining the location of
orbital tumor.
Down and out: The lesions in the superonasal quadrant will cause
abaxial proptosis in the down and out position, and are associated with
frontal and ethmoidal mucocele and meningocele.
Down and in:
Lesions in the
superior-temporal
quadrant will result
in abaxial proptosis
as in patients with
lacrimal gland tumor
and external angular
dermoid. (Figure 4)

Figure 4: Abaxial proptosis with downward
displacement by a lacrimal gland pleomorphic adenoma

Basic Examination of Oculoplasty | 21

Upwards: Pathologies arising from the floor of the orbit, maxillary
sinus, and metastatic tumor can cause abaxial proptosis. (Figure 5)

Figure 5: Abaxial proptosis with upward displacement caused by a mass arising
from the maxillary sinus

Laterality

The common causes of unilateral and bilateral proptosis have been
summarized in table 2.

Ocular Motility

Limitation of ocular motility limitation in a case of proptosis can be
either due to direct involvement of extra-ocular muscles or due to
palsy of the individual nerves supplying the extra-ocular muscles.

Peri- orbital
inflammation

Pain, redness, swelling
and induration of
surrounding peri-orbital
tissues are associated
with infections and
acute inflammation.
(Figure 6)

Figure 6: Peri-orbital inflammation with erythema
of overlying skin in a patient with orbital cellulitis

22 | Basic Examination of Oculoplasty

Eyelids
Eyelid retraction with lateral flare is characteristic in patients with
thyroid ophthalmopathy. Lids can also be involved due to direct
compression of levator palpebrae superioris and third cranial nerve.
(Figure 7)

Figure 7: Eyelid retraction with lateral flare in a patient with thyroid eye disease

Neighboring structures
Nose, palate, and sinuses must be examined as pathologies like
aesthesioblastoma, fungal infections like mucormycosis and
aspergillosis can be associated with the simultaneous involvement of
the nasal mucosa and surrounding sinuses.
Maneuvers
Valsalva, bending forward
An increase in proptosis on performing Valsalva maneuver or on
bending forward can be seen in patients with orbital varix and arterio-
venous malformation. Capillary hemangioma characteristically
increases in size on crying.
Ocular Examination
A detailed ocular examination is a part of complete proptosis work-up.
Visual acuity: Visual acuity can be reduced either due to the tumors
arising from the optic nerve or due to compression of the optic nerve
by the lesion.

Basic Examination of Oculoplasty | 23

Pupillary examination: Optic nerve involvement results in relative
afferent pupillary defect

Intraocular pressure: Increased episcleral pressure in patients with
carotid cavernous fistula is associated with increased intraocular
pressure.

Ocular surface and fornices
Ocular surface should be examined to look for salmon patch in a
patient of lymphoma. Scleritis, or scleral nodules can be associated
with granulomatous inflammatory disorders like sarcoidosis. Dilated
lymphatic channels (lymphangectasia) can be seen in patients with
veno-lymphatic malformation.

Anterior segment
On anterior segment examination, Lisch nodules can be found
in patients of neurofibromatosis. Uveitis can be associated with
inflammatory orbital disorders and granulomatous diseases.

Fundus examination: Blurred disc margins and choroidal folds can be
seen in patients with retrobulbar lesions. Optic atrophy can ensue due
to compression of the nerve by intraconal tumor.

Palpation

1. Thrill/pulsations

Index and middle fingers are placed over the tumor with eyes
closed, and the movement of fingers is observed. A pulsation felt
or observed over the mass can be either due to arterio-venous
malformation, carotid-cavernous fistula or from a saccular
aneurysm of the ophthalmic artery. The transmitted cerebro-spinal
fluid pulsations are due to abnormal communication between
the orbit and central nervous system as in cases of congenital
meningocele or meningo-encephalocele, traumatic or post-
operative hiatus in the orbital roof.

2. Retropulsion

In the retropulsion test, the globe is gently pushed backward with
the thumb/ two fingers/ palm placed over the closed upper lid.

24 | Basic Examination of Oculoplasty

Resistance to retropulsion is felt in patients with orbital tumor,
depending on the nature (solid/ cystic) and size of the tumor.

3. Orbital margin/ rim: With the index finger the surrounding
orbital rim and margins are palpated to look for bony changes.
In long-standing benign lesions, there can be associated fossa
formation. Bony erosion is associated with malignancy and
bony irregularity or step deformity can be associated with orbital
fractures

4. Infraorbital/ supraorbital nerve infiltration by malignancies
such as adenoid cystic carcinoma often results in orbital pain,
paraesthesia which is frequently associated with the perineural
spread.

5. If the orbital lesion is palpable, the following should be noted:
Margins, surface, consistency, mobility, adhesion to the overlying
skin and underlying structures. Tenderness and increased
temperature of overlying skin suggests infectious or inflammatory
etiology

6. Trans-illumination

Trans-illumination test helps evaluate the anterior orbital lesions
and is performed with the help of a pen-light. If the lesion is filled
with clear fluid as in dacryops, the area lights up more than the
surrounding tissues.

However, in a solid tumor like osteoma, and organised dermoid
cyst the illuminated area is opaque and appears to be darker than
the surrounding tissues. This is interpreted as a negative trans-
illumination test and indicates the constituents.

7. Deep palpation

For palpation of orbital tumors beyond the orbital rim, the patient
will look in the opposite direction to the mass located, and the
examiner presses his fingertip over the surface. After this patient
looks in the the same direction of orbital mass (thereby relaxing
the septum), the examiner’s fingertip reaches beyond the orbital
rim for deeper palpation

Basic Examination of Oculoplasty | 25

Auscultation

Bruit on orbital auscultation can be present in patients with the high
flow vascular malformations, like caratoid-cavernous fistula. Orbial
auscultation is performed by gently placing the stethoscope over the
closed eyes and should include the zygomatic and lateral regions as
well as the skull. In order to correlate the acoustic phenomena with
cardiac activity, the radial pulse is palpated simultaneously. A pulse-
synchronous “machine noise” over the orbit is pathognomonic for a
carotid–cavernous sinus fistula.
Pulse-synchronous noises can also occur in orbital/cerebral
AV malformations, in intracranial space-occupying masses with
raised intracranial pressure, as well as in other diseases such as
vascularized tumors and bone defects (e.g., sphenoid wing aplasia in
neurofibromatosis).

Exophthalmometry

Hertel’s exophthalmometer
The examiner must be at the same level as that of the patient, and the
right eye must be kept closed while examining the right side and vice
versa to reduce parallax error. The orbital notch on the temporal side
is first palpated, then the patient is asked to look straight ahead. The
examiner first aligns the red lines in the prisms by moving the head
slightly laterally so that a single line is visible.

Figure 8: Hertel’s exophthalmos-meter

26 | Basic Examination of Oculoplasty

The apex of the corneal reflection, as seen in the prism and its
corresponding value in millimeters, is noted. The readings indicate
the anterior distance from the cornea to lateral orbital margins, and in
normal individuals is the same for both sides. Figure 8
The normal values are in the range of 7-19mm, 7-21mm, 12-21mm,
12-20mm, 12-24mm, and 12-23mm for Indian, Caucasian, and African
males and females, respectively.
Limitations: Readings are affected by poor fixation. The readings
also cannot be obtained in patients with depressed /fractured lateral
orbital rim, convergence error, and abnormal head movements.
Luedde exophthalmometer
Luedde exophthalmometer is a transparent thick plastic millimeter
ruler with markings on both the sides.
The notch on scale conforms to the angle of the lateral orbital rim,
and scale readings are from 0mm (end of the notch) to 40mm.
Parallax is minimized by overlapping the corresponding scale
markings on both sides of the rod.
Measurement of globe dystopia
Horizontal dystopia is measured by the distance from the the midline

Figure9: Measurement of globe dystopia

Basic Examination of Oculoplasty | 27

of the bridge of the nose to the nasal limbus, and is compared
bilaterally.
Vertical dystopia is measured by the superior or inferior deviation of
the central corneal reflex of the proptotic eye from a horizontal line
passing through the center of the normal eye. (Figure 9)
Limbus test of motility of Kestenbaum: This test is performed by
holding a transparent millimeter ruler horizontally in front of the
cornea. In measuring abduction, the location of the nasal limbus
point is noted on the ruler in the primary position and maximum
abduction. The difference immediately gives the degree of abduction
in millimeters. Adduction is measured similarly by determining the
positions of the temporal limbus.
To measure elevation and depression, hold the ruler vertically. The
examiner should test each eye with his or her homonymous eye.
Normal values established by Kestenbaum are 10 mm for adduction,
abduction, and depression, and 5 to 7mm for elevation.

28 | Basic Examination of Oculoplasty

Examination of a case
of Lid tumor

Eyelid and peri-ocular skin lesions are very common in patients,
with a benign lesion of the eyelid contributing to 80 percent of eyelid
neoplasms, while malignant tumors account for the remaining. Benign
and malignant lid tumors can arise from each layer of the eyelid,
which includes skin and subcutaneous tissue including its adnexa,
striated muscle, tarsus with the meibomian glands, and the palpebral
conjunctiva. Most commonly the tumors arise from the skin and
conjunctiva. The tumors of cutaneous origin, are mostly epidermal
and can be divided into epithelial and melanocytic tumors.

Relevant History

• Age at Presentation:

alignant lesions usually

present in the older age

group, malignant tumors

generally present in the

6th to 7th decade, on the

contrary, the benign lesions

can present in both young

and older age groups.

However, in patients with Figure 1: A child with Xeroderma
defective DNA repair pigmentosa with basal cell carcinoma

mechanisms as in cases of

xeroderma pigmentosa the manifestation of lid tumor can be early

- Presence of family history and syndromic associations are found
in the following syndromes: Muir torre syndrome (sebaceous
gland carcinoma), xeroderma pigmentosa, basal cell nevus
syndrome, albinism, Bazex syndrome and Rombo syndrome.

Basic Examination of Oculoplasty | 29

- Duration of presenting complaints: malignant tumors show faster
growth as compared to the benign tumors.

- Any history of ionizing radiation, thermal burns or scars,
immunosuppression, recurrent inflammation, or redness
predisposes for the development of malignancy. Patients with
a history of HIV infection are at a risk for the development of
squamous cell carcinoma.

Clinical examination of a lid mass

The clinical examination of a lid mass includes

• Site of lesion
Sebaceous cell carcinoma is more commonly present in the upper

lid, due to a higher number of meibomian glands in the upper
gland. Squamous cell carcinoma and basal cell carcinoma are
more commonly present in the lower lid. The tumors in the medial
canthus are predisposed for orbital invasion.

• Size and extent of the lesion
Horizontal and vertical length with a thickness of the tumor

should be measured. Destruction of eyelid margin, with loss of
lashes, indicates the malignant transformation. One should also
look for the involvement of fornices/ canthus, and usually point
towards the orbital involvement.
The involvement can be limited to anterior lamella or posterior
lamella or full-thickness.

• Discoloration of the overlying skin
Pigmentation is usually seen in patients with melanocytoma, and

melanoma and rarely in patients with pigmented squamous cell
carcinoma , and pigmented basal cell carcinoma.
Nevus flammeus in Sturge Weber syndrome is associated with
purple hue, and Kaposi sarcoma presents with a diffuse blue Sub-
cutaneous lesion.

30 | Basic Examination of Oculoplasty

• Appearance/ surface

Squamous papilloma can
be sessile or pedunculated,
and typically has a
cerebriform convoluted
surface. (Figure 2)

Seborrheic keratosis, is a
discrete brown, a round or
oval lesion with a friable
verrucous surface.

Keratoacanthoma is a Figure2: Squamous papilloma of the
premalignant lesion for the upper lid

development of squamous

cell carcinoma and has a typical appearance of a crater filled with

keratin.

• Overlying skin

In a benign lesion, there is a lack of induration or ulceration with
regular outline and preservation of normal lid margin structures.
On the other hand, malignant lesions have rapid growth with
nodulo-ulcerative lesion, bleeding, crusting, destruction of lid
anatomy, and loss of cilia. A yellowish hue with a lobulated
surface is typically seen in sebaceous cell carcinoma. (Figure3)

Figure 3: Sebaceous cell carcinoma
Basic Examination of Oculoplasty | 31

• Margins
The margins in basal cell carcinoma are usually rolled out everted

and heaped up. There may be associated necrosis of the overlying
skin.
The margins are ill-defined in infiltrative, sclerosing malignancies,
and can be well defined in sebaceous gland carcinoma, squamous
cell carcinoma, and melanoma
• Examination of fornix
Fornix should be examined for congestion, infiltration, and extent
of involvement of lesion, punctal involvement in a medial canthus
lesion can present with persistent watering. (Figure 4) Pagetoid
spread in sebaceous cell carcinoma can present with conjunctival
inflammation.

Figure 4: Squamous cell carcinoma

• Signs of orbital invasion
Proptosis, limitation of extraocular movement, and globe dystopia

are the signs of an orbital invasion.

Palpation

The findings of the inspection are confirmed on palpation. Inability
to palpate the posterior edge of the tumor indicates orbital extension.
The mass must be palpated for its consistency, fixity to underlying
structures (tarsus/ bone). (Figure 5)
Everted lid examination is very important to document the extent an
involvement.

32 | Basic Examination of Oculoplasty

Figure 5: Everted examination of the lid, showing the involvement of tarsus

Lymph node examination

The common lymph node groups to be involved in patients with lid
malignancy are, preauricular, parotid, submandibular, and anterior
cervical lymph node.

Examination of
lymph nodes

The lymphatic Inner canthus
drainage of the lymph vessel
eyelids has been
summarized in Figure Outer canthus
6 lymph vessel

The preauricular Inferior eyelid
lymph nodes are lymph vessel
palpated anterior to
the tragus of ear and Preauricular
the retro-auricular lymph node
lymph nodes are
palpated behind the Submandibular
ear, on the mastoid lymph node
process.
Figure 6: Lymphatic drainage of eyelid
Submental lymph
nodes can be palpated
under the chin. The

Basic Examination of Oculoplasty | 33

examiner stands behind the patient, and the patient is instructed to
bend his/ her neck slightly to relax the muscles and fascia. Fingers of
both hands can be placed just below the chin, under the lower border
of mandible.

For sub-mandibular lymph nodes, the patient is instructed to passively
flex the neck towards the side being examined, the palmar aspect of
the fingers is then pushed on to the soft tissue below the mandible near
the mid-line. Parotid and neck lymph nodes must also be palpated.

The common sites of lymphatic spread are pre-auricular and parotid
group of lymph nodes.2

Differentials Basal cell Squamous Sebaceous Eyelid
carcinoma cell cell melanoma
carcinoma carcinoma

Demography 60-80 > 60 years(1) 50-60 Fair, tanned,
years(1) years(1) with history
of multiple
nevi

Most com- Lower lid Lower, Upper eye- No specific
mon site near medial lid areas lid causing predilction
canthus of actinic loss of lid
Appearance damage or architecture
Nodular, chemical
ulcerative, exposure
superficial,
sclerosing, Roughened Initially Pigmented
pigmented lesion.
kind scaly plaque resembles 5-10%
is most
common telangiec- chalazion, amelanotic
variety
tasia later after

+/- ulcer- invasion

ation/ crust- yellowish

ing, cast

Nodulo-ulcer- through

ative the skin,

nodulo

ulcerative

34 | Basic Examination of Oculoplasty

Staging of malignant eyelid tumors, AJCC, 2017
Basic Examination of Oculoplasty | 35

Reference

1. Kale SM, Patil SB, Khare N, Math M, Jain A, Jaiswal S. Clinicopathological
analysis of eyelid malignancies - A review of 85 cases. Indian J Plast Surg.
2012 Jan;45(1):22-8.

2. Vuthaluru S, Pushker N, Lokdarshi G, Kumar R, Bajaj MS, Kashyap S, Mathur
S, Chawla B, Khurana S, Ghose S. Sentinel lymph node biopsy in malignant
eyelid tumor: hybrid single photon emission computed tomography/computed
tomography and dual dye technique. Am J Ophthalmol. 2013 Jul;156(1):43-
49.e2.

36 | Basic Examination of Oculoplasty

Evaluation of Lacrimal
System

Epiphora

Epiphora is overflowing of tears. True epiphora is watering due to
obstruction in the lacrimal drainage system. Anatomical block is
referred to obstruction due to structural pathologies like punctal
stenosis, canalicular block, and nasolacrimal duct obstruction. In
replace functional dysfunction by physiological dysfunction of the
lacrimal pump, but the anatomical outflow pathway is patent. The
lacrimal pump mechanism failure can arise from seventh nerve palsy,
and eyelid laxity due to aging.
Hyper-lacrimation is due to excessive production of tears due to severe
dry eye or irritation of corneal or conjunctival surface associated with
foreign body or infection.

History

A detailed history must be taken, about the onset of the complaints.
Congenital nasolacrimal duct obstruction can present with watering
a few days after birth. Previous history of trauma or surgery of the
lacrimal sac must also be included. Canalicular trauma if not repaired
can lead to proximal/ distal canalicular block. (Figure 1)

Figure 1: Post-traumatic telecanthus with epiphora

Basic Examination of Oculoplasty | 37

Examination of a case of epiphora

Eyelid examination
Eyelid examination is done to look for eyelid laxity, medial canthal
laxity, presence of trichiasis, and blepharitis.

Eyelid laxity

Medial canthal tendon laxity

This test is performed by pulling the lower lid laterally from the
medial canthus, and the displacement of the medial punctum is noted.
The greater the displacement, the greater is the laxity. Normally the
medial canthus can be displaced by 0-1 mm only.

Lateral canthal tendon laxity

This test is performed by pulling the lower lid medially from the lateral
canthus corner, greater
the displacement of the
lateral canthus greater is
the laxity. Normally the
lateral canthus can be
displaced 0-2mm only
Tear meniscus height
(Figure2)

Normal tear meniscus Figure 2: Tear meniscus height (Picture courtesy:
height is 0.16-0.35mm. Dr. Anju Bhari, Senior Resident, R.P. Centre)
Failure of drainage of the
tears leads to an increase
in the tear meniscus
height.

Lacus lacrimalis

Lacus lacrimalis, or lacrimal lake is collection of tears, in the lower
conjunctival fornix around the caruncle A collection of the lacus
lacrimalis, indicates lacrimal system obstruction.

Lacrimal punctal examination

The lacrimal puncta is situated at the medial end of the ciliary part of

38 | Basic Examination of Oculoplasty

the lid margin along the line of meibomian gland openings surrounded
by a ring of fibro-elastic tissue. The size of the puncta is 0.4-0.6, and
a size less than 0.2 mm implies punctal stenosis. Puncta can be dilated
up to 5 times its normal size. (Figure 3)
Primary punctal disorders are associated with punctal agenesis,
punctal stenosis, supernumerary puncta, and ectopic punctum.

Figure 3: Normal puncta

Secondary punctal disorders can be due to punctal trauma, punctal
ectropion, iatrogenic punctal disorders, and in cases of ocular
cicatricial pemphigoid and Steven-Johnson syndrome. Centurion
syndrome is an idiopathic abnormal anterior insertion of medial
canthal tendon, which shifts the puncta away from lacus lacrimalis
causing continuous watering.

Examination of conjunctiva and caruncle

Conjunctiva and caruncle must be examined to look for other causes
of hyper-lacrimation, like conjunctivoch-alasis, follicle, papilla, and
impacted foreign body.
Presence of discharge with congestion near caruncle point towards
chronic dacryocystitis.
A megalocaruncle can sometimes occlude the opening of the puncta
or displace the puncta away from the globe.

Test for tear film stability

Schirmer’s test
Schirmer’s strips are prepared using Whatman filter paper # 41, in a

Basic Examination of Oculoplasty | 39

dimension of 5mm by 35 mm, a tab of 5mm at one end of the strip
is to be folded. Markings are made at a distance of 5mm beginning
below the tab from 5mm to 35 mm and can also labeled right and left
for the ease of use. The folded tip is inserted into the lower lid – at
the junction of the middle and outer thirds of the lower lid – taking
care not to touch the cornea or lashes. The patient is asked to keep
their eyes closed for the duration of the test. After 5 minutes, the filter
paper is removed and the amount of wetting from the fold is measured.
Measurement of >15mm after 5 minutes is normal.

Tear film break uptime (TBUT)

To measure TBUT, fluorescein is instilled into the patient’s tear film
and the patient is asked not to blink while the tear film is observed
under a broad beam of cobalt blue illumination. The TBUT is recorded
as the time elapse between the last blink and the appearance of the first
dry spot in the tear film.

Normal tear film break up time is 10 seconds, 5-10 seconds is the
marginal and less than 5 seconds is considered to be low.

Test for obstruction of the lacrimal system

1. Regurgitation test
Regurgitation test is performed by applying gentle pressure over
the lacrimal sac area, with either thumb or index finger, and puncta
is observed. A regurgitation of fluid on applying pressure over the
lacrimal sac signifies the patent canalicular system with block in
the lower end of sac or When positive, the type of regurgitate is noted
which can be watery, mucoid, mucopurulent or blood- stained. Clear
watery fluid is seen in atonic sac. Reflux of mucoid or mucopurulent
material is indicative of nasolacrimal duct obstruction.

2. Syringing

After instillation of the topical anesthetic drops, the punctum and
a ampulla are dilated with the help of punctal dilator. The punctum
and proximal canalicula can be stabilized with a finger on the lower
eyelid retracting the lid inferiorly. A blunt cannula is placed in the
inferior canaliculus and the lower eyelid is pulled down and laterally

40 | Basic Examination of Oculoplasty

in order to straighten the lower canaliculus and evert the punctum
away from the ocular surface. The superior canaliculus is gently
stretched laterally prior to irrigation. The tip of the irrigator is placed
in the inferior canaliculus, first vertically and then horizontally with
the eyelid on stretch. The tip is advanced as far as possible till the sac
and saline is usually used as an irrigant.

The regurgitation of fluid is noted:

- Regurgitation of mucoid discharge with hard stop shows
nasolacrimal duct obstruction.

- Regurgitation of clear fluid from the same puncta with a soft stop
shows canalicular block, where as regurgitating clear fluid from
the opposite puncta and soft stop is likely to be due to common
canalicular block.

The feeling of saline taste in the throat suggests a patent nasolacrimal
duct system. However, the test does not rule out functional abnormality.

Diagnostic probing

Probing is done only if an obstruction is found on syringing, and is
performed with the help of Bowman’s probe. After dilating the puncta,
the Bowman’s probe is inserted first vertically and then horizontally.
Hard stop and soft stop are also observed. In patients with the patent
canalicular system a hard stop is observed and in patients with a
canalicular block soft stop is observed. According to the distance at
which the soft stop is felt from the puncta, the canalicular block can
either be proximal, mid or distal. Proximal blocks have involvement of
the proximal 2–3 mm of the canaliculus from punctum, mid-canalicular
obstructions 3–8 mm from the punctum, and distal obstructions as
defined by a membrane at the opening of the common canaliculus to
the lacrimal sac.(Figure 4)

Figure 4: Nettleship punctal dilator

Basic Examination of Oculoplasty | 41

Jones dye test
Jones dye test is a physiological test, in which fluorescein is instilled
in the cul-de-sac and a cotton swab is placed in the inferior meatus.
The change in color of the cotton swab is observed.

Jones dye test 1:
The test differentiates partial obstruction of the lacrimal passages and
lacrimal pump failure from primary hypersecretion of tears.

A drop of 2% fluorescein is instilled into the conjunctival sac of one
eye only.

After about 5 minutes, a cotton-tipped bud moistened in local
anaesthetia is inserted under the inferior turbinate at the nasolacrimal
duct opening. The results are interpreted as follows:

• Positive: fluorescein recovered from the nose indicates patency
of the drainage system. Watering is due to primary hypersecretion
and no further tests are necessary.

• Negative: no dye recovered from the nose indicates a partial
obstruction (site unknown) or failure of the lacrimal pump
mechanism.

Jones dye test 2:

Jones dye test 2 is performed only if the Jones dye test 1 is negative.
A cotton-tipped bud moistened in local anaesthesia is inserted under
the inferior turbinate at the nasolacrimal duct opening, and irrigation
is performed.

Presence of dye on the cotton tip after irrigation, indicates partial
naso-lacrimal duct obstruction.

Absence of dye in the nose suggests, total obstruction of lacrimal
drainage system or defective lacrimal pump mechanism.

Jones dye test 3 In patients with DCR the cotton swab is kept in the
middle meatus and staining of the swab is observed after instillation
of the dye.

42 | Basic Examination of Oculoplasty

Fluorescein dye disappearance test

The dye disappearance test is a simple physiological bedside test that
can be performed both in children and adults. The test is performed
under topical anesthesia. A drop of 2 % fluorescein is instilled in the
conjunctival fornix. After 5 minutes the amount of dye retained is
observed. The dye disappears spontaneously and symmetrically in 5
minutes in normal eyes. The test is most useful when symptoms of
epiphora are asymmetric.

Saccharin test

Saccharin test is a physiological test, under topical anesthesia, a drop
of 2% saccharin is instilled in the cul-de-sac. In a normal person, the
average time to taste saccharin is 3.5minutes, if no taste is felt after 20
minutes, then it suggests obstruction of the lacrimal system. The other
eye is tested after 30 minutes

Imaging for lacrimal system obstruction

Imaging in lacrimal system obstruction is indicated in patients with a
history of facial trauma, haemolacria, suspicion of lacrimal sac mass,
and in cases of failed DCR.

Dacryocystography

Dacryocystography is performed by injecting the contrast material
into canaliculus (lipiodol, pentopaque,dianosil) following which
serial scans are taken at 5 and 30 mins for visualisation of canaliculus,
lacrimal sac and nasolacrimal duct. This helps to find the exact site,
nature and extent of obstruction. Dacryocystography is performed :

– to confirm site of obstruction prior to surgery

– to aid in diagnosis of diverticula, fistula, filling defects caused by
any stone or tumour in the sac.

Dacryocystography is contra-indicated in patients with acute
dacryocystitis.

Dacryoscintigraphy

Nuclear lacrimal scintigraphy is a non-invasive physiological

Basic Examination of Oculoplasty | 43

test for the evaluation of the lacrimal system,and is performed
using a radiotracer, which can be detected with a gamma camera.
Scintigraphy is useful in studying tear dynamics, and its main use is in
the evaluation and confirmation of lacrimal pump dysfunction. A drop
of technetium-99m is instilled into each conjunctival sac of a patient
sitting in front of a gamma camera and images recorded at frequent
intervals. Anatomical details are not clearly visualized, but the transit
time for the passage of the dye from the canaliculi to the nasal cavity
is an indicator of physiological lacrimal system.

CT Dacryocystography

CT-DCG uses a water-soluble radio-opaque dye. A drop of Iodixanol
dye is instilled in the conjunctival cul-de-sac (diluted with sterile
water in the ratio 1:1 to a concentration of 135 mg/mL), and serial
films are taken.

Ultrasound biomicroscopy

Ultrasound biomicroscopy uses high-frequency ultrasound 50 –
100MHz probe. The probe is placed initially at a site 5mm lateral to
the lacrimal punctum, and then slowly shifted towards the medial
canthus, and is placed vertically to the palpebral margin.

In normal individuals, the canaliculi are in a collapsed state. In
patients with canaliculitis, the canaliculus can be obstructed and
filled with mucus, debris, and concretions which can be visualized
with the ultrasound bio-microscopy. But the limitation of ultrasound
biomicroscopy is the difficulty in placing the transducer directly and
limited penetration.

References

1. Liarakos VS, Boboridis KG, Mavrikakis E, Mavrikakis I. Management of
canalicular obstructions. Curr Opin Ophthalmol. 2009;20:395–400.

44 | Basic Examination of Oculoplasty

Examination of a Case of
Entropion and Ectropion

Relevant History

Entropion is the inward turning of the lid margin and can be due
to congenital or acquired causes. The acquired entropion can be
involutional, cicatricial or spastic.

The patients with entropion usually present with watering, redness,
and foreign body sensation.

Entropion presenting from birth suggests congenital entropion,
similarly entropion present in old age points towards involutional
entropion.

Cicatricial entropion can result from burns, trauma, chemical
injury, trachoma, Steven’s Johnson syndrome, and ocular cicatricial
pemphigoid. The painful irregular ocular surface can result in spastic
entropion.

Examination

Lid margin
There is an inward turning of the lid margin, depending on the degree
of the same, entropion can be

Grade 1: Only the posterior border is in rolled

Grade 2: Inward turning up to the inter-marginal strip

Grade 3: Whole lid margin including the anterior border is in turned.

Lid margin keratinization can be seen in patients with Steven Jonson
syndrome. In cicatricial entropion, there can also be associated
symblepharon.

Basic Examination of Oculoplasty | 45

Examination points for involutional entropion
Lid laxity
Patients with involutional entropion usually have associated lid laxity.
Lid laxity can be determined by
Pinch test
The lid is pulled away from the globe and the distance by which the
lids can be pulled away, determines the lid laxity. If the lid can be
8mm from the globe it suggests laxity.1

Figure 1: Pinch test

Weakness of lower lid retractors
– The laxity of lower lid retractors is indicated by Higher eyelid

resting in primary gaze
– Failure of lid to retract down on downgaze Increased depth of

inferior fornix
– Presence of white infra-tarsal band of retractors separated from

lower tarsal border by a reddish orbicularis band
Snap back test
The lower lid is pulled away and down from the globe for a few
seconds, and the time required by the lid to return to its original
position is noted. Normal lid springs back immediately to its original
position, more the time the lid takes to return to its original position,
the more is the laxity present.

46 | Basic Examination of Oculoplasty