Subtarsal eyelid examination using an oblique slit lamp mirror in cases of eyelid shortening

Sir,

We report a novel technique enabling examination of the superior fornix and tarsus in patients in whom the eyelid cannot be everted.

Case report

An 89-year-old man presented to ophthalmic A&E with a painful right eye and foreign body sensation. He had recently had extensive right upper eyelid surgery with full thickness excision of a Merkel Cell tumour at another unit (Figure 1a). A corneal abrasion was found postoperatively in his right eye. To investigate the cause of the abrasion, attempts were made to evert his upper eyelid. However, owing to the horizontal shortening as a consequence of his recent surgery, this was not possible.

Figure 1.

(a) Photograph of the right upper eyelid following resection of a Merkel Cell tumour and subsequent reconstruction illustrating a horizontally shortened eyelid, which could not be everted. (b, c) The oblique slit lamp mirror placed under the upper eyelid margin to highlight the fluoroscein-stained suture that had caused the corneal abrasion. (d) The suture is removed visualised indirectly with the slit lamp mirror.

By distracting the eyelid away from the globe and placing the detached slit lamp oblique mirror (Figure 2a) under the eyelid margin, the tarsus and superior fornix could be easily seen (Figure 1b). Using this technique, we were able to identify a Vicryl suture within the tarsal wound (Figures 1b and c), which was also easily removed with the aid of mirror (Figure 1d). The patient was treated with chloramphenicol ointment and the corneal abrasion resolved within 1 week.

Figure 2.

The oblique slit lamp mirror.

Comment

In cases of a corneal abrasion, inverting the upper eyelid to exclude a foreign body is an essential step of the ocular examination.¹ However, everting the eyelid may be difficult in cases of previous surgery or in the presence of a cicatrical disease such as ocular cicatricial pemphigoid. In certain circumstances, eversion of the upper eyelid may also be contraindicated after eyelid surgery owing to the risk of disrupting the wound. In such cases, the oblique mirror from the slit lamp is a useful alternative to examine the superior fornix and tarsal surface. We advise cleaning and disinfecting the mirror using the same standard methods as used for other ophthalmic instruments such as a three-mirror contact lens.

Previous reports have described the use of a nasopharyngeal or a dental mirror as a useful aid in similar situations,^{2, 3} these are however not readily available in most eye departments.

The authors declare no conflict of interest.