Review of Cornea & Contact 

lenses

How Lid Malposition Can Compromise Contact Lens Wear

Keep these conditions in mind to prevent or rectify potential obstacles to a successful fit.

By Steven Turpin, MS, and Leonid Skorin Jr., OD, DO, MS

Release Date:

October 2016

Expiration Date:

October 1, 2019

Goal Statement:

Eyelid anatomy and the tear film are important structures to consider during a contact lens fit. This article addresses abnormal lid anatomy and strategies for managing these scenarios.

Faculty/Editorial Board:

Steven Turpin, MS, and Leonid Skorin Jr., OD, DO, MS.

Credit Statement:

This course is COPE approved for 1 hour of CE credit. COPE ID is 51130-CL. Please check your state licensing board to see if this approval counts toward your CE requirement for relicensure.

Joint Sponsorship Statement:

This continuing education course is joint-sponsored by the Pennsylvania College of Optometry.

Disclosure Statement:

Drs. Turpin and Skorin have no financial interest in any products mentioned in this article.


While the cornea and sclera are considered critical points to monitor during the contact lens fit, the patient's eyelid anatomy and tear film are also important. Some of the first lenses ever made were designed to prevent corneal exposure in a patient whose eyelid had been partially destroyed by cancer, highlighting the importance of these parts of the ocular anatomy.1 Approximately 130 years after this fitting, optometrists are still using contact lenses to manage eyelid disorders; as such, adequate awareness of the interaction between the contact lens and eyelids for the purpose of preventing additional problems is a skill that eye care practitioners should focus on and keep up to par. 

Among other concerns, certain lid issues that can arise may lead to an increased risk of infection due to ocular adnexa dysfunction such as misdirected lashes, abnormal lid anatomy, cranial nerve palsies and blepharitis. These issues and their treatments can further impede contact lens success, resulting in patient discomfort and possibly even dropout from lens wear altogether. This article will primarily focus on the presentation of abnormal lid anatomy and the existing strategies for management of these scenarios. 

Surgery as a First-line Strategy
For patients who present to the clinic with a lid malposition issue, surgery is often considered the first-line treatment to correct their problem. Regardless of the condition, the primary goal of the eye care practitioner is to restore both form and function to the eyelid and relevant periocular structure by addressing the cause of the problem—that is, the undesirable alteration in the patient's lid anatomy. 


Fig. 1. Ptosis of the right upper eyelid in a patient with Horner's syndrome. Note the miotic right pupil.

Once this is done, the contact lens fitting process following surgery is similar to that of fitting a patient who has not undergone a procedure, as almost all existing lens modalities can be considered for use. However, if surgery is contraindicated, the procedure's outcome is not optimal, or the patient simply has additional lid issues (e.g., narrow palpebral fissures, excessively tight lids or large lid angles), then certain contact lenses are contraindicated for fitting, limiting practitioners to the selection of a lens from options that are considered more lid independent.

For such patients with suboptimal eyelid anatomy or function, scleral contact lenses are the best option, as they are generally least influenced by lid anatomy. In decreasing order of suitability, sclerals are followed by spherical soft lenses, multifocal and toric soft lenses and, finally, corneal rigid gas permeable lenses (especially translating multifocals), which rely on the wearer's lids for positioning and movement, making them least suited for use by patients with lid issues.3 Taking into account the level of lid dependency of a lens can increase the chance of lens wear success by patients with more severe lid abnormalities or in lieu of further surgical correction. Below, lid conditions and their treatments for rectification are covered. 

Ptosis
Also known as blepharoptosis, this common lid malady manifests from one of a variety of different causes including congenital developmental malformations, trauma, myasthenia gravis or Horner's syndrome (Figure 1). Regardless of any underlying etiology, however, the problem most often involves either insufficient levator contraction due to incorrect or weak muscle insertion into the superior tarsal plate or myogenic issues like those seen in muscular dystrophy or various nerve conduction problems.4 For example, paresis of the third cranial nerve causes severe ptosis as a result of innervation to the levator being lost in some fashion. Ptosis is typically graded based on an assessment of remaining levator function and treated accordingly: mild to moderate ptosis (i.e., greater than 4mm of levator function remaining), for example, is managed via the reattachment of the aponeurosis of the levator to the tarsal plate, or by the shortening of the levator above Whitnall's ligament, which both serve to improve function. 

Patients with complex or more severe cases of ptosis (i.e., less than or equal to 4mm of levator function), however, are treated via the insertion of a silicone rod or other suspensory material to enable frontalis suspension. Twenty-five percent of severe ptosis patients who undergo this procedure also end up suffering post-surgery from some form of exposure keratopathy.5 The risk of corneal damage also increases significantly if ocular motility is restricted or if orbicularis function is reduced, so additional measures are often taken in order to maintain the integrity of the ocular surface. These include the use of artificial tears or lubricants in mild cases to therapeutic scleral lenses in moderate to severe cases.6 Increasing the thickness of a standard scleral lens can also help with improving the cosmetic appearance of the eyelids and also prevent the upper lid from covering the pupillary axis; this solution can prevent restriction of the superior visual field if the patient elects to forgo surgery or if the operation itself is contraindicated.7 

Specialty scleral contact lenses can also be manufactured with either a shelf for the lid to rest on or props to hold it in place.7,8 However, practitioners should keep in mind that long-term wear of scleral lenses in this scenario simply masks the lid problem rather than permanently correcting it at the source: in effect, the lenses act as crutches, and so should only be used as temporary measures or if surgery has entirely been ruled out. 


Fig. 2. Severe ectropion of the left inferior lid. Note that the inferior punctum is also turned out.

If the patient does undergo surgery for the lid condition and wishes to return to soft lens wear afterwards, corneal changes resulting from the operation should be kept in mind as these can adversely impact the success of the lens fit. Pressure from the uneven upper lid prior to surgery can also cause the superior cornea to steepen, altering corneal astigmatic power and axis.9 The superior cornea then flattens following the lid procedure and can influence both the refraction and the fit of the lens. 

The eye care practitioner should fully reevaluate all contact lens patients wishing to return to contact lens wear following lid surgery to record any changes that might necessitate alterations in lens parameters. Note, gas permeable lens wear is not recommended for patients who have undergone ptosis surgery as rigid lens wear is linked to the development of ptosis itself.1 

Contact lens-induced ptosis (CLIP), a variation on the previous condition, is a phenomenon that has been observed since the 1980s; however, its exact pathophysiology has yet to be established. An existing hypothesis for its onset involves the occurrence of a forced blinking action during which the patient attempts to open their eyes wide enough to remove their contact lenses. In this instance, the resulting simultaneous contractions of both the levator and orbicularis oculi are believed to increase traction on the levator aponeurosis, causing its dehiscence.10 Different theories suggest that it may be the lateral pulling of the eyelid—common during lens removal—that creates high amounts of lid tension followed by repeated hard blinks that then lead to the exertion of high amounts of pressure on the palpebral portion of the upper lid.11 

However, regardless of the possible anatomical changes, rigid lens wear can increase a patient's risk of developing ptosis 17-fold.1 Those patients who do use gas permeable lenses and exhibit CLIP should cease wear for at least one month to allow for spontaneous resolution. If this does occur, refitting the patient in soft lenses is often a viable solution, though soft lens wear also does increase the risk for ptosis development up to five times more compared with non-lens wearers.1 If resolution does not occur, surgical intervention is indicated, with selection of the technique determined by the amount of remaining levator function as detailed above. Regardless of the cause of ptosis, however, consider a different modality other than gas permeable lenses for wear following resolution of the issue.12

Ectropion
Present almost exclusively in the lower lid, this condition involves the outward turning of the lid margin (Figure 2). The most common subtype of ectropion, involutional ectropion, results from tissue changes made that increase the laxity of the tarsus or canthal tendons.4 In the case of ectropion, it is also common for the inferior punctum to turn outwards, where it impedes normal tear drainage; as a result, epiphora is a frequent complaint among patients with this condition. 

Practitioners should keep in mind that just a few simple tests can be used to assess lid laxity: one example, the snap-back test, involves asking the patient to look upwards as their lower lid is pulled down gently. Depending on the lid's response following release, the condition can be graded as either normal (i.e., the patient's lid returns to its original position quickly); mild (i.e., the lid slowly returns); moderate (i.e., the lid incompletely returns on its own, requiring the patient to blink); or severe (i.e., even with blinking, the lid does not return to its original position).12 


Fig. 3. Severe lid laxity manifesting as entropion.

Cases of lid laxity can be localized to either the medial or lateral canthi or the tarsal portion of the lid, which may influence the selection of surgical technique for repair. In most instances of a patient with involutional ectropion, a simple tightening of the lateral canthus and performance of a tarsal strip procedure works to solve the problem; however, if malpositioning of the punctum is a concern, a medial spindle procedure may also be necessary.13 For patients in which canthal laxity is not a problem, a pentagonal wedge resection of the tarsal portion of the lid is preferable to other procedures to fix the issue.4 Furthermore, in the case of an uncontrolled systemic disease presenting in conjunction with the lid problem (i.e., hypertension, diabetes, vascular disease or cardiac disease) that makes surgery too risky to perform, a scleral lens can be used to prevent corneal exposure.14,15

Patients with involutional ectropion who wear either soft or rigid lenses may experience discomfort prior to surgery, both from the lenses riding low and also from a decrease in tear film distribution, which can lead to lens dryness. These issues are generally solved and normal lid function is restored following the appropriate surgical intervention. As mentioned earlier, changes in lid structure—both before and after surgery—significantly affect the fit of rigid corneal lenses; thus, they often require adjustments accordingly. 

Corneal changes can also take place after lower lid tension is restored, as the increased pressure on the inferior cornea can increase the degree of with-the-rule astigmatism that a patient may have, possibly affecting the soft lens fit or making a toric lens a more appropriate option.16 If a toric soft lens is indicated for the patient, lid procedures can help improve rotational stability by reducing the palpebral fissure.2 Better lid tension has yet to be proven to make any significant difference in the case of lens stability, however.2,17 

Ectropion may also result from damage done to the seventh cranial nerve, either by trauma, surgery or conditions such as Bell's palsy. This is subcategorized as paralytic ectropion and may be associated with a larger number of possible complications. As such, the reduction or loss of orbicularis oculi function may require a more complex surgical intervention than in the case of involutional ectropion; additionally, induction of artificial ptosis either via a botulinum toxin injection or lid weight can lessen levator activity, temporarily protecting the cornea from exposure.18 This way, ocular lubricants and other necessary topical medications can still be instilled as needed. In some cases, treatment may need to go as far as the performance of a tarsorrhaphy procedure (i.e., the suturing of the superior and inferior lids together to protect the corneal surface).4 Placement of a scleral contact lens is also once again an option in such cases. 

Entropion
Many of the physiological changes that result in ectropion may also lead to entropion, which is the inward turning of the lid margin (Figure 3). The snap-back test used to assess lid function in the case of ectropion can also be useful here if entropion is suspected: practitioners should simply look for the lower lid margin turning in instead of outwards. Directing the patient to close their eyes tightly can also elicit an entropic turning in of the lid margin. Ultimately, if this is the diagnosis, treatments include injections of botulinum toxin made to the orbicularis oculi muscle for temporary relief, as the botulinum toxin breaks the involuntary muscle contraction pattern characteristic of spastic entropion.12 A more permanent solution is for the patient to undergo capsulopalpebral reattachment to the base of the tarsal plate to restore both form and function to the lower lid.  


Fig. 4. Floppy eyelid syndrome increases the risk of spontaneous eversion of the upper lid during sleep and subsequent corneal damage.

Ensuring corneal protection is imperative for patients suffering from entropion, as the inward turning of the eyelashes can cause epithelial erosion or even corneal ulceration or stromal scarring. If surgery to correct the lid problem cannot be performed promptly, a bandage soft lens can help protect the ocular surface. Scleral contact lenses may also help shield the cornea from insult, though they themselves can cause a pseudoentropion if fit with an insufficient diameter.1 Postoperative fitting issues in patients with resolved entropion are similar to those found in individuals who have undergone ectropion surgery because good lid tension is restored in both cases. Keratometric readings preoperatively and postoperatively are not usually significantly different, though key changes can be found if corneal topography is performed correctly.19

Keratoconus and Floppy Eyelid Syndrome
Traditionally, the standard for correction of patients with keratoconus has been the use of corneal gas permeable contact lenses. These typically provide patients with optimal vision; however, one consideration that can change the eye care practitioner's treatment strategy is when a keratoconic patient has concurrent floppy eyelid syndrome (FES), which is characterized by excessive lid elasticity, especially in the upper eyelid (Figure 4). In one study, 11 out of 60 subjects with FES also exhibited corneal changes that were characteristic of keratoconus, while other research has found that an underlying connective tissue defect may link the two conditions together.20,21 Regardless, however, it can be difficult to fit these patients with corneal gas permeable lenses due to the level of existing lid laxity, so other modalities like scleral, hybrid or keratoconic-specific soft lens designs can stand in as suitable alternatives. Such options may provide these patients with good vision without the need to rely on the eyelids for proper lens positioning. 

Aside from addressing a patient's visual needs, eye care practitioners must also ensure the patient's cornea is protected at night in cases of FES. Spontaneous eversion during sleep is a problem that is common among keratoconic patients with this condition with irritation and damage being made to the ocular surface. It can be treated using ocular lubricants or eye shields worn while sleeping; should these fail, however, another option is surgical repair, during which the medial canthopexy and lateral tarsal strip procedures are combined. This procedure can reduce lid elasticity while maintaining both the upper eyelid tarsus and punctal positioning.22 

Though it can result in changes to the anterior segment, surgery remains the best option for fixing eyelid malposition problems. Eye care practitioners should remain aware of the changes associated with eyelid procedures and be willing to make changes in their selection of contact lenses following the procedure. They must also keep in mind that bandage soft or scleral lenses can temporarily protect the ocular surface. Though the peak age of occurrence of many lid problems is long after the peak age of habitual contact lens wear, the fitting principles common to normal wearers apply to these patients as well.   

Mr. Turpin, an optometry student at Pacific University College of Optometry, plans to graduate in 2017.

Dr. Skorin practices ophthalmology at the Mayo Clinic Health System in Albert Lea, MN.

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