2. EYELID
1. Evaluate the symmetry and relative position of the eyebrows.
2. Note position of eyelashes relative to the globe, density of lashes, and
their color
3. Note the position, movement and symmetry of eyelids
4. Note previous surgery or injury
5. To assess eyelid closure, ask the patient to blink and then to close
both eyes gently. Any gap that allows exposure of the ocular
surface (ie, lagophthalmos) is noted and measured.
4. EYELID
Interpalpebral Fissure Height
Ask the patient to fixate a penlight in primary gaze position.
Hold a millimeter ruler vertically, close to the patient’s open eye,
to measure the distance between the center of the upper and
lower eyelid margins
Record the interpalpebral fissure height in millimeters for each
eye.
To recheck the measurements, obtain and add together the
following 2 measurements:
The distance between the upper eyelid margin and the corneal light reflex
(normally about 4 mm).
The distance between the lower eyelid margin and the corneal light reflex
(normally about 6 mm).
5. EYELID
Upper Eyelid Margin–Corneal Reflex Distance
Hold a penlight directly in front of the patient, so that the
patient observes it in primary gaze and a corneal light reflex is
present.
Use a millimeter ruler to measure the distance between the
center of the upper eyelid margin and the corneal light reflex.
Record the margin–reflex distance for each eye. Use a negative
number if the light reflex is obstructed by the eyelid.
6. EYELID
Upper Eyelid Crease Position
Use a penlight or other near target to bring the patient’s gaze into the
primary position.
Measure the distance between the upper eyelid margin and the upper
eyelid crease.
Record the upper eyelid crease position for each eye. Note if the
upper eyelid crease is absent and cannot be accurately measured.
7. EYELID
Levator Function
Either hold a thumb on the brow or place the palm of your hand against the
patient’s forehead. This maneuver prevents the frontalis muscle from
assisting with upper eyelid elevation, thereby isolating the action of the
levator muscle.
Ask the patient to look down, and align the zero point of the millimeter ruler
with the patient’s upper eyelid margin; take care not to touch the patient’s
eyelids or eyelashes.
Do not move the ruler. Ask the patient to look up as far as possible. Keeping
the ruler steady, measure the new location of the upper eyelid margin. The
difference between the 2 measurements gives the levator function.
Record the levator function in millimeters for each eye.
11. EYELID
• Upper eyelid retraction is assessed with the patient’s gaze in
the primary position; where the upper eyelid margin crosses the
globe in relation to the superior limbus should be noted.
• Patients with eyelid retraction might also exhibit eyelid lag (von
Graefe sign), which is a delayed or fluttering eyelid movement
on downward pursuit.
• To detect lower eyelid retraction, first have the patient fixate
on a target, such as your finger. While you look at the suspect
eye, have the patient follow your finger as you move it
downward until the lower eyelid margin of the patient’s other
eye rests at the lower limbus. Observe whether any sclera
shows between the eyelid margin and limbus of the involved
14. PROPTOSIS
• Position yourself directly in front of the patient. Your left
eye measures the patient’s right eye, and your right eye
measures the patient’s left eye.
• Hold the exophthalmometer so that the angled mirrors are
oriented upward, above the fixation foot plates.
• If a patient’s previous intercanthal reading is known, set
the last recorded distance between the patient’s lateral
canthi on the scale. If this is the patient’s first reading,
place the instrument so that the foot plates rest on both
lateral orbital rims at the level of the outer canthi.
• With your left eye, sight along the right-hand mirror of the
instrument at the reflection of the patient’s right eye.
• Instruct the patient to occlude their left eye with a hand or
occluder and to look toward your eye to achieve straight-
ahead alignment.
•Using your open left eye, align the instrument’s
2 vertical markers (usually a long vertical line in
the center of the proptosis scale and a
corresponding mark or line on the instrument’s
base).
•Read the distance from the lateral orbital rim to
the corneal apex by noting where the mirror
image of the patient’s anterior-most corneal
curvature falls along the mirror’s millimeter
ruler. Note that you see the anterior corneal
surface from the side; the reading is the
anterior extent of the corneal apex on the
gauge.
•Obtain a similar measurement for the patient’s
left eye by using your right eye to align the
appropriate vertical markers on the opposite
mirror of the instrument.
•Record the readings for each eye and the
distance between the lateral canthi
16. The different types of exophthalmometers used to measure the globe position.
A: the Hertel exophthalmometer
B: the Leudde exophthalmometer
C: the Naugle exophthalmometer
D: the Mourits exophthalmometer.
17. LACRIMAL SYSTEM
• Raising patient’s upper eyelids
• Instructing patient to look downward and medially.
• Observe and note any lacrimal gland masses
• Observe the lacrimal puncta for apposition to the globe and patency
• Observe lacrimal sac for swelling and erythema
• Eversion, stenosis, occlusions and fuctional obstruction.
• Observe overflow tears
18. LACRIMAL SYSTEM
Dye disappearance Test
o Berikan pewarna fluorescein pada kedua mata pasien
o Lihat dengan menggunakan cahara cobalt blue untuk memastikan fluorescein terlihat
o Tunggu 5 menit, minta pasien untuk tidak menghapus air mata/ pewarna
o Periksa kembali tear meniscus pasien:
1. Normal tear film clear
2. Obstruksi air mata masih berwarna
For any patient with blepharoptosis, the examiner must measure interpalpebral fissure height, upper eyelid margin–corneal reflex distance, upper eyelid crease position, and levator function.
Snapback test
How to perform
The middle portion of the lower eyelid is pulled inferiorly away from the globe until the lid is fully displaced. After releasing the lid, it should immediately return to contact the globe in a healthy lower eyelid.
Interpretation
The grading scale depends on how long the lower lid takes to spring back into the globe.
Grade 0: takes less than 2 seconds
Grade I: takes 2 or 3 seconds
Grade II: takes 4 or 5 seconds
Grade III: takes more than 5 seconds but returns to its normal position with blinking
Grade IV: never returns back to the normal position
Lower lid distraction test. a. The lower lid is pulled from the globe and the distance is measured. b. Lid distraction greater than 6 mm is considered abnormal.
There are several types of exophthalmometers: Hertel and Luedde exophthalmometers measure the distance of the corneal apex from the level of the lateral orbital rim, while Naugle exophthalmometers measure the relative difference between each eye.
Masukan punctal dilator untuk memperlebar punctum
Masukan probe ke punctum tegak lurus dengan eyelid margin kemudian parallel dengan kanalikuli sambil menarik kelopak kearah lateral
Rasakan tahanan dari probe (soft stop/ hard stop)
Ganti probe dengan syringe irigasi
Masukan cairan irigasi kedalam system lakrimal
Lihat apakah ada refluks/secret yang keluar atau tanya pasien apakah terasa ada air yang mengalir ke hidung/mulut
