金台診所醫學美容的部落格

By Prof Dr.Gehad Elnahri

The Lower Eyelid

Examination of the lower eyelid is rich in clinical signs. Truly it shares many of its diseases with the upper eyelid but it has several exclusive features

1)Blepharitis; is always more severe and more evident in the lower eyelid. We can guess some of the reasons; 
-the lower meibomian glands have to secrete against gravity which makes their clogging easier, 
-plus it is more exposed to environmental factors and gravitation of any chemical and drugs in the tear film.
-the lower lid is also continuous with the cheek; a sensitive area of the face susceptible to many skin diseases that commonly involve the lower lid like rosacea 



2)Malpositions; working against gravity and having a small tarsus makes the lower lid more susceptible to malpositions except ptosis
-entropion; spastic and cicatricial entropion are more common in lower lid
-ectropion; paralytic ectropion is unique for the lower lid and all types are much more common esp mechanical and cicatricial
-ptosis; lower lid ptosis is paradoxical rising on the cornea (reverse or inverse ptosis). It occurs in cases of enophthalmos (floor fracture, orbital decompression) or shrinkage of the globe. It can follow surgery of the inferior rectus muscle (resection) and may be present in Horner's syndrome (fig 1).
-lid retraction; the sclera becomes exposed. It can accompany upper lid retraction in TED or occur alone in congenital Euryblepharon (fig 2). It can follow IR recession.

3)Masses; BCC is much more common in the lower eyelid and should be in the dd of any lower eyelid swelling above 50 yrs (fig 3,4,5)



4)The lower fornix; although belongs to the conjunctival sac, clinically examination of the lower fornix is part of the lower eyelid examination. What do we look for in the lower fornix?
-Anemia; being less affected by trachomatous fibrosis, the lower fornix is the place to look for pallor of anemia
-Follicles; are seen in the lower fornix in viral conjunctivitis; non-trachomatous chlamydial conjunctivitis (fig 6) and drug reactions (more common than upper ?gravitation). They can be seen in normal children as a part of general lymphoid hypertrophy (Folliculosis of children, fig 7)
-Papillae are not seen in the lower tarsus (no rubbing with globe or contact lenses)
-Drug pigmentation; adrenochrome deposits and argyrosis (fig 8,9) are seen in the lower fornix
-Symblepharon; mild and early symblepharon are best detected in the lower eyelid because movement of the upper lid is a relative protective factor against symblepharon. Symblepharon appearing for the first time above 50 years is strongly diagnostic of ocular cicatricial pemphigoid (10,11,12).