What Lies Beneath (the Eyelid)
BY WILLIAM TOWNSEND, OD
Danielle, a 20-year-old college student who has been our patient for over a decade, called our office complaining of bilateral ocular irritation. She was a long-time disposable contact lens wearer
wearer with good compliance and hygiene. The patient had a strong history of atopic disease. She was going to college far from home, working through the summer as a lifeguard. When she began to have ocular irritation, she sought help.
An ER doctor initially diagnosed a corneal abrasion. The topical aminoglycoside drops he prescribed only made the discomfort worse. Danielle then saw a corneal specialist and explained to him that the discomfort began when she started working at the pool. Perhaps some water had splashed into her eyes. He noted a bilateral diffuse corneal stippling and diagnosed chemical keratitis. He advised the patient to discontinue the antibiotic, stop contact lens wear and begin using non-preserved artificial tears.
When she presented to our office, Danielle complained that her discomfort was worse when she removed the contact lenses. She also complained of ocular itching. Visual acuities were 20/40- and slit lamp exam showed mildly coated lenses and excess mucin. After removing the lenses, we noted bilateral SPK that was worse in the left eye.
The Answer Lies Beneath
Eversion of the lids revealed bilateral giant papillae, again more prevalent on the left lid. We diagnosed vernal kerato-conjunctivitis exacerbated by but not caused from wearing contact lenses. We recommended total cessation of lens wear and prescribed Zaditor drops bid. After using this combination antihistamine/ mast cell stabilizer for one week, the patient's condition improved both objectively and subjectively. She eventually was able to successfully resume contact lens wear without discomfort or irritation.
Make Lid Eversion a Routine
Routinely evert the upper eyelids of any patient with ocular pathology. Also, habitually evert the lids of your contact lens patients. We have learned the hard way that lid eversion can be the key to correctly diagnosing many anterior segment conditions.
Patients do not particularly like lid eversion, but it is a useful means of examining the conjunctival tarsal surface. This is often the key to diagnosing chlamydial disease, discovering unsuspected foreign bodies and detecting immune-based conditions such as GPC, vernal conjunctivitis, atopic conjunctivitis and vernal kerato-conjunctivitis. Failure to evert may delay proper diagnosis for many months.
Lid Eversion Guidelines
Avoid eversion if the patient has a severe penetrating lid laceration or a puncture wound through the lid. You should not evert the lids of patients with suspected globe rupture. In virtually all other situations, it is permissible to evert the lids.
Some situations demand lid eversion. When a patient presents with a corneal foreign body, the examining doctor needs to make sure that there is not a foreign body under the eyelid. Evert the lids any time a contact lens patient experiences more discomfort after removing the lenses. For patients that present with coated lenses or excessive mucous, evaluate their tarsal conjunctiva by eversion. Evert the lids of all patients with significant allergies, especially if they complain of itching. Also, evert the lids of patients with chemical burns to rule out the possibility that particulate matter has been trapped under the lid.
Lid eversion is a basic procedure that we all could do more often to benefit our patients and ourselves.
Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at email@example.com.