When we begin an examination of the eyes we note first the relative positions of the orbits, any swelling of the face, or other morbid condition, especially on the side of the affected eye, and note any swelling in the region of the preauricular gland, or of the lymphatic glands of the neck. Then we note the position of each lid, the condition of its skin and of its margin, the presence of any liquid or dry discharge between or on them, and of any scurf, scabs, sores, swellings, or other abnormality that may be present. Sometimes we need to observe the movements of the lids in the act of winking, or to test their sensibility when there is any reason to think of a possible anesthesia or hyperesthesia.
THE LIDS Certain defects may be present in the lids, and we need to know whether they are congenital or acquired. A lid that is too short, partially or wholly absent, may be congenital, but in that case scars are absent, and there is no history of traumatism. A coloboma may vary in size from a notch at the margin, to a fissure which runs the whole width of the lid and involves its entire thickness. If it is artificial we find its margins cicatricial and can obtain a history of traumatism, as a rule, while if it is congenital its margins are covered by conjunctiva, sometimes are attached to the surface of the eyeball by synechie, or the defect is associated with dermoid, and the condition has existed since birth. Very rarely two colobomata may be present with a semi-detached piece of the eyelid between them, resembling a double harelip.
<Callout type="important" title="Critical Observation">When examining for congenital defects in the lids, it is crucial to note the absence of scars and history of trauma.</Callout>
EPICANTHUS The base of a baby’s nose frequently appears to be too broad, with each of the inner canthi covered more or less by a crescentic fold of skin. This condition persists normally among the Mongolian races, but among Caucasians it usually disappears in a few years with the growth of the child. Occasionally it persists and then forms a congenital anomaly known as epicanthus, which almost always is bilateral and not to be mistaken for anything else. In the majority of cases it is slight, and of importance only in so far as it impairs the beauty of the face, but sometimes the folds of skin are so large as to cover not only the canthi and the caruncles, but also a large part of the inner portions of the lids, giving rise to a serious deformity and interfering with vision. These pronounced cases are apt to be associated with other congenital anomalies, especially ptosis, and strabismus may be simulated even when it is not present.
PTOSIS One or both of the upper lids may droop; this is called ptosis. This condition varies in degree from a very slight droop that gives the face a sleepy expression, to one in which the lid hangs down loosely and covers the pupil, rendering the eye practically blind. It may be congenital or acquired. The differentiation is made usually from the history and the presence or absence of lesions known to be capable of its production.
<Callout type="warning" title="Potential Vision Loss">Severe ptosis can significantly impair vision by covering the pupil, making early detection critical.</Callout>
Congenital Ptosis The testimony of the parents that the droop has been present since birth, or of the patient himself that he has had it as long as he can remember, ordinarily suffices for a diagnosis of congenital ptosis. The only probable chance of error is in the case of the rare disease chronic progressive ophthalmoplegia, but this can be excluded by an examination into the motility of the extrinsic muscles, for although this may be impaired to a greater or less degree in both, secondary contractures will be found in the muscles only when this disease is present. If the ptosis is associated with epicanthus, strabismus, or nystagmus, or if there is no diplopia when the lid is lifted, we may be pretty sure that the ptosis is congenital.
Key Takeaways
- Identify eyelid conditions such as coloboma and epicanthus to differentiate between congenital and acquired defects.
- Recognize the signs of ptosis, including its varying degrees from mild drooping to severe vision impairment.
- Understand the importance of patient history in diagnosing congenital versus acquired ptosis.
Practical Tips
- Use a flashlight to illuminate the eye area during examination for better visibility of eyelid conditions.
- Inquire about family medical history when suspecting congenital defects like ptosis or epicanthus.
- Test lid movement and sensitivity to rule out anesthesia or hyperesthesia in suspected cases.
Warnings & Risks
- Severe ptosis can lead to significant vision loss if not addressed promptly.
- Misdiagnosis of chronic progressive ophthalmoplegia as congenital ptosis is possible; always check motility of extrinsic muscles.
Modern Application
While the diagnostic techniques described in this chapter are still relevant today, modern medical imaging and neurological assessments provide more precise methods for diagnosing conditions like ptosis. Understanding these historical approaches remains valuable for emergency triage situations where advanced diagnostics may not be immediately available.
Frequently Asked Questions
Q: What is the significance of a coloboma in the eyelid?
A coloboma can vary from a small notch at the lid margin to a complete fissure running its entire width. If it involves the conjunctiva or synechie, it is likely congenital and has been present since birth.
Q: How does one differentiate between congenital and acquired ptosis?
Congenital ptosis can be diagnosed based on patient history indicating its presence from birth. Acquired ptosis often results from trauma, disease, or neurological conditions and requires further investigation into the cause.
Q: What are the potential complications of severe epicanthus?
Severe cases of epicanthus can interfere with vision by covering a large part of the inner portions of the lids. It may also be associated with other congenital anomalies such as ptosis and strabismus.