This month’s theme of diagnostic skills and techniques gave me a chance to reflect on the amazing growth the profession has achieved in our clinical responsibilities. The downside is that scope expansion necessitates some picking and choosing among us all: we’re approaching the point where we simply can’t do it all. 

With that in mind, I tasked myself with coming up with advice I believe can offer the most benefit for the most readers. If I can convey one message around the subject of diagnosis, it’s to take a whole new look at the eyelids. Because of meibomian gland dysfunction, lids are responsible for about 86% of all dry eye disease.1 And, of course, other lid-related problems abound.

Here are five tips for better lid assessment and care in your practice:

1. Examine the lash base. Research shows that long-standing blepharitis from Staphylococcus or Demodex, even at low-grade levels, can lead to significant morbidity, including loss of lashes, meibomian gland atrophy and chronic dry eye.2 However, many cases of significant blepharitis go undiagnosed unless you have the patient look slightly down and run your slit beam across the base of the lashes, looking for collarettes on the lashes or biofilm escaping the follicles.

2. Express the glands. It is difficult to successfully treat dry eye without determining the type, and you can’t do this well without expressing the MGs. There are two ways to assess the health of the meibomian glands directly: meibography and MG expression. For the latter, use an expression tool such as the Mastrota Paddle (OcuSoft). At the slit lamp, place the paddle behind the lower central to nasal eyelid and your thumb on the outside of the lid. Move the paddle upwards while pressing gently. 

No anesthetic is necessary. Normal expression is clear and thin like olive oil. Abnormal is thickened, turbid, paste-like or non-expressible. Another effective tool is the Meibomian Gland Evaluator (Johnson & Johnson Vision). 

3. Measure lid laxity. A quick and easy test to measure ectropion and lid laxity is to pull down the lower lid and observe how quickly it returns to normal position. It should happen almost instantly. Some patients with chronic ocular surface symptoms have lid laxity and, therefore, few treatments will help them. For entropion, perform the “squeeze test” by having patients squeeze their eyelids forcefully to see if this induces an entropion.

4. Observe eyelid closure. Start looking for patients with any of these three symptoms and you’re likely to uncover lids that don’t seal tight at night: inferior corneal staining, morning symptoms of discomfort or a positive K-B light test. The test, developed by Drs. Korb and Blackie, has become so important I find myself using it on 100% of my patients with dry eye symptoms. Have the patient close their eyes (not squeeze) as they would during sleep. In a darkened room, place a transiluminator (or penlight) above the tarsal plate of the outside closed eyelid. A beam of light that passes through the two eyelids indicates a poor lid seal. 

5. Take on ptosis. Until recently, there was little we could do to improve the appearance or functioning of this condition, shy of surgical options. In congenital forms ptosis can result in amblyopia, and in acquired forms it can indicate a life-threatening condition. However, for the vast majority, ptosis is an age-associated dehiscence of the levator aponeurosis that makes patients feel and look old and affects their visual field. Upneeq (oxymetazoline 0.1%, Osmotica), recently FDA approved as a once-daily drop to treat acquired blepharoptosis, is an alpha-1 and partial alpha-2 adrenergic agonist capable of contracting Müller’s muscle. In Phase III trials, treatment was well tolerated and significantly improved the superior visual field.

I can’t overstate how important the eyelids are in the diagnosis and care of so many anterior segment diseases we manage. If there is just one area where it would behoove you to perfect your diagnostic skills and techniques, the eyelids are it.

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chairman of the affiliated New Technologies & Treatments conferences. A fixture in optometric clinical education, he provides consulting services to a wide array of ophthalmic clients. Dr. Karpecki’s full disclosure list can be found here.

1.  Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-8. 

2.  Rynerson JM, Perry HD. DEBS - a unification theory for dry eye and blepharitis. Clin Ophthal-mol. 2016;10:2455-2467.