Basic Examination of Oculoplasty Booklet 2

Grades
Normal: Lid returns back immediately
Grade 1: Lid comes back after1-2 seconds
Grade 2: Lid comes back after 2-4 seconds
Grade 3: The lid comes back to its position on blinking
Grade 4: Lid continues to hang down.2

Figure 2: Snap back test

Medial canthal 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.
Grades
Mild –When the lid can be pulled 2mm laterally and does not reach
the medial limbus
Moderate -When the lid can be pulled up to the mid limbus.
Severe-When the lid can be pulled across through the pupil3
Lateral canthal 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. Grades of lateral canthal laxity

Basic Examination of Oculoplasty | 47

Grade 0- 0-2 mm displacement
Grade 1-2-4 mm displacement
Grade 2- 4-6 mm displacement
Grade 3->6mm dispalcement4.

Figure 3: 3a Lateral canthal tendon laxity, 3b Medial canthal tendon laxity

Figure 4: Involutional entropion

Examination of cicatricial entropion

Lid margin: Lid margin in a patient with cicatricial ectropion should
be examined to look for lid margin keratinization and metaplastic
lashes. (Figure 5, 6)

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Figure 5: Metaplastic lashes (Picture credits: Dr. Neha Yadav, Senior resident RP
center, AIIMS)

Figure 6: Lid margin keratinization

Symblepharon; Symblepharon is defined as the abnormal adhesion
between the palpebral conjunctiva and bulbar conjunctiva.
Symblepharon can be anterior, posterior, or complete.

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Anterior: In anterior symblepharon, the abnormal adhesions are
limited to the anterior lid margin only. In posterior symblepharon on
the contrary the adhesions are limited to the fornices.

In complete/ total symblepharon the adhesions are present throughout
from anterior to posterior.

The different types of symblepharon can be differentiated with the
help of probe test.

Probe test for symblepharon: A bowman’s probe is tried to pass beneath
the symblepharon if the probe can be easily passed then it suggests
only anterior symblepharon, however, incomplete symblepharon the
probe cannot be passed.

Digital eversion test: The lids are everted and the tarsal plate is
palpated. A thick tarsal plate is usually associated with chronic
fibrosis, as in cases of trachoma. Thinning of tarsus is associated with
chemical injury and Steven Johnson syndrome. One can also pull the
lids superiorly. If the lids cannot be pulled 2mm above the limbus,
then it indicates deficient posterior lamella.

Lagophthalmos: The inability to close the eyes even on forced closure,
signifies posterior lamella shortening, and hence is an important
clinical sign for surgical planning.

Slit-lamp examination in entropion

Entropion can be associated with trichiasis, blepharitis, meibomitis,
resulting in corneal dryness. Hence slit-lamp examination in a
case of entropion is done to look for the corneal status, persistent
epithelial defects, and corneal tear film stability. Moreover, associated
conjunctival scarring and conjucntivalisation of the cornea can
contribute to the poor ocular surface.

In cases with ocular cicatricial pemphigoid and Steven-Johnson
syndrome, punctal stenosis can also be associated and must be looked
for.

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Grading of upper lid cicatricial entropion
(Kemp and Collin)

Degree Clinical feature

Mild Apparent migration of meimobian gland
Conjunctivalisation of lid margin
Moderate Lash globe contact on upgaze
Severe
Mild + Thickening of tarsal plate with lid retraction

Gross lid distortion
Metaplastic lashes
Presence of keratin plaque
Lid retraction causing lagophthalmos

Figure 7: Thickened tarsal plate

Spastic entropion

Orbicularis muscle tone : To check for the tone of the orbicularis
muscle, the patient is asked to squeeze his eyes shut. Worsening of
entropion is noted in a patient with weakness of orbicularis muscle

Grades of orbicularis muscle tone:
Grade= no paralysis
1= weak
2=normal
3=overactive
4=spastic

Basic Examination of Oculoplasty | 51

Ectropion

Ectropion is the outward turning of the lid margin and can be congenital
or acquired. The acquired causes of ectropion include involutional,
cicatricial, mechanical, and paralytic causes.

The symptoms in a case of ectropion of result from corneal exposure
resulting in foreign body sensation, exposure, and inadequate
lubrication. Facial palsy, lid trauma, ocular allergy, and history of
previous lid surgery must be taken into consideration.

Test for ectropion
Pinch test
Snap back test
Medial canthal tendon laxity
Lateral canthal tendon laxity

Position of lacrimal puncta
Punctum alone or the entire lid can be everted, in a normal lid, the
punctum is well apposed to the globe and is visible only after pulling
down the lid. A punctum directed away from the globe may be the
earliest sign of medial lid ectropion. Ectropion can be graded as
follows
Grade1: Punctal eversion
Grade 2: Lid not apposed
Grade 3: Visible palpebral conjunctiva with eversion of lid margin
Grade 4: Fornix is visible with eversion of lid margin

Cicatricial skin changes
Cicatricial ectropion results from shortening of the anterior lamella,
which can result from trauma, surgery, burns, and scarring after herpes
zoster. The scars should be examined to look for their extent, and
maturity, A mature scar is flat and light-colored and an immature scar
is red elevated, painful, and itchy

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Figure 8: Cicatricial ectropion with lagophthalmos in a child with facial burns

References

1) Marcet MM, Phelps PO, Lai JS. Involutional entropion: risk factors and surgical
remedies. Curr Opin Ophthalmol. 2015 Jul;26(5):416-21.

2) Ozgur OK, Murariu D, Parsa AA, Parsa FD. Dry eye syndrome due to botulinum
toxin type-A injection: guideline for prevention. Hawaii J Med Public Health.
2012;71(5):120-123.

3) Ibrahim HA, Sabry HN. Classification and management of ectropion with medial
canthal tendon laxity. J Egypt Ophthalmol Soc 2014;107:263-7

4) Glat PM, Jelks GW, Jelks EB, Wood M, Gadangi P, Longaker MT. Evolution of
the lateral canthoplasty: techniques and indications. Plast Reconstr Surg. 1997
Nov;100(6):1396-405; discussion 1406-8.

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Basic Examination of Oculoplasty | 55

Prof. (Dr.) Namrata Sharma

Secretary, Delhi Ophthalmological Society

DELHI OPHTHALMOLOGICAL SOCIETY

Room No. 479, 4th Floor, Dr. Rajendra Prasad Centre for Ophthalmic Sciences,

56 | BAEalmlsIaincidl:[email protected]/iepdnolcasersset,[email protected]·, India Tel: +91-11-2086371
Website: www.dosonline.org