Examination of the Conjunctiva
The conjunctiva is examined by direct inspection. The bulbar conjunctiva is directly visible between the eyelids; the palpebral conjunctiva can only be examined by everting the upper or lower eyelid. The normal conjunctiva is smooth, shiny, and moist. The examiner should be alert to any reddening, secretion, thickening, scars, or foreign bodies.
Eversion of the lower eyelid.The patient looks up while the examiner pullsthe eyelid downward close to the anterior margin (Fig. 1.7). This exposes the conjunctiva and the posterior surface of the lower eyelid.
Eversion of the upper eyelid.Simple eversion(Fig. 1.8). The patient is asked tolook down. The patient should repeatedly be told to relax and to avoid tightly shutting the opposite eye. This relaxes the levator palpebrae superioris and orbicularis oculi muscles. The examiner grasps the eyelashes of the upper eyelid between the thumb and forefinger and everts the eyelid against a glass rod or swab used as a fulcrum. Eversion should be performed with a quick levering motion while applying slight traction. The palpebral conjunctiva can then be inspected and cleaned if necessary.
Full eversion with retractor.To expose the superior fornix, the upper eyelid isfully everted around a Desmarres eyelid retractor (Figs. 1.9a and b). This method is used solely by the ophthalmologist and is only discussed here for the sake of completeness. This eversion technique is required to remove for-eign bodies or “lost” contact lenses from the superior fornix or to clean the conjunctiva of lime particles in a chemical injury with lime.
Blepharospasm can render simple and full eversion very difficult especially in the presence of chemical injury. In these cases, the spasm should first be eliminated by instilling a topical anesthetic such as oxy-buprocaine hydrochloride eyedrops.