Examination Of The Lower Eyelid

    The lower eyelid is evaluated for excessive skin, herni¬ated orbital fat, retraction, inferior hollowing, and laxity.

Lower eyelid skin-fat examination
    The excessive skin in the lower eyelid is considered as the patient looks upward. This position places the skin on the stretch needed to look upward, and any extra skin with the eyelid in this position usually can be sacrificed without fear of producing a cicatricial ectropion postoperatively. If the amount of excessive skin is determined with the patient looking straight ahead or downward and if the excessive skin in these positions is excised, the patient might have an ectropion on up gaze.

 

Figure 3-8 The margin reflex distance-! (MRD,) is useful for determining the amount of ptosis. This is the distance from the light reflex on the patient's cornea to the central upper eyelid as the patient gazes in the primary position. The difference in MRD, between the normal and the ptotic lid determines the amount of ptosis.

    Herniated orbital fat in the lower eyelid is judged by determining fullness in the medial, central, and temporal areas of the eyelids when the patient looks upward. To differentiate fat from edema, the examiner applies pressure to the eye through the upper eyelid. Increased fullness in the lower eyelid correlates with fat herniation; no change in fullness is seen if edema is present. Also, the examiner must consider hypertrophy of the orbicularis muscle, which can be emphasized by having the patient smile. Smiling also demonstrates lower eyelid wrinkles that might be treated with botox, skin flap plications, laser resurfacing, or chemical peels. Nasojugal depressions or inferior orbital rim hollowing should be examined as they might require orbital fat repositioning or cheek lifts.