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Oculoplasty Basics: Clinical Work up proformas

Article · September 2020

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 Oculoplasty basics: Clinical work up proformas

Sujeeth Modaboyina, MD

Neelam Pushker, MD

Sahil Agrawal, MD

Oculoplastic, Pediatric Ophthalmology& Oncology Services,

Dr Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences,
New Delhi, India

Corresponding Author:

Dr.Sujeeth Modaboyina, MD
Senior Resident
Oculoplastic, Pediatric Ophthalmology & Tumor Services,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences
New Delhi –110 029, India
Ph.: 9177599507
Fax: +91-11-26588919 (R.P. Centre)
Email : [email protected]
Introduction
During clinical examination of patient before filling the following proforma complete ophthalmic
examination should be done. Filling the proforma along with basic workup proforma helps in
identifying the etiology, localizing the pathology and planning surgical approach. This chapter
will include proformas for working up proptosis, ptosis, contracted socket, ectropion/entropion
and eyelid tumors. We would like to highlight staging, grading and various examination steps for
working up the patients.

Proptosis work up
Inspection
1. Vision

2. Facial asymmetry
3. Proptosis (Axial/
Abaxial )
4. Hertel’s
exophthalmometry
(Bar reading- )

5. Globe dystopia (mm)

(horizontal/ vertical)

6. Lid fullness/ Skin

changes/ Other

7. TED signs `

8. Extra ocular
movements
(Kestenbaum limbus
test)
9. Conjunctival findings
 10. Cornea

11. Pupillary reaction

12. Fundus examination –

Choroidal folds / optic
disc

13. Valsalva maneuver

 Palpation

Location

Extent

Margins
Consistency

Tenderness

Pulsations/
Thrill/Refill
time

Compressibility

Temperature
Resistance to
retropulsion

Bony margins

Lymph nodes

 Auscultation (bruit)

 Old photographs

 Any other relevant

findings

Proptosis: Proptosis is defined as a forward (anterior) displacement of globe in

relation to skull- measured by protrusion of the apex of the cornea in front of outer
orbital rim. The term ‘exophthalmos’ is reserved for globe protrusion secondary to
endocrinological dysfunction1.

Exophthalmometry: Exophthalmometry (proptometry) measures in an anterio-

posterior plane i.e., the distance between the apex of the cornea and a bony point
usually taken to be the deepest portion of the lateral orbital margin with the eye

.
looking straight ahead Subjective assessment is done by worms eye view and
Nafziger test. Objective assessment is done by using hertel and luedde
exophthalmometre

Worms eye view: We will ask the patient to tilt his head upwards and we will look
from below to protrusion of eyeball in relation to other normal side.

Fig. 1: worms eye view

Nafziger test: In Nafziger test examiner will stand behind patient and will look
from above patient head. After bring upper and lower orbital margins in the same
plane, corneal visibility and its relative position compared to other side will be
assessed.

Hertel exophthalmometer: The examiner must be at the same level as that of

patient and right eye must be kept closed while examining right side and vice versa
to reduce parallax error. With closed eyes, locate the orbital notch on the temporal
side of the orbit and place the concave contact points. The bar readings of the
exophthalmometer is very important and must always be noted in case the patient
needs to be re-examined in future. The patient is then told to open their eyes and
look straight ahead. The examiner must align the red lines in the prisms by moving
head slightly laterally so that single line is visible. The tip of the corneal reflection
as seen in the prism and its corresponding value in millimeters is noted. The
reading is usually the same in each eye and indicates the anterior distance from the
cornea to lateral orbital margins. The normal values are in the range of 7-19mm, 7-
21mm, 12-21mm, 12-20mm, 12-24mm and 12-23mm for Indian, Caucasian and
African males and females respectively2.

figure2: Hertel exophthalmometer

Limitations: Readings are affected by poor fixation, depressed /fractured lateral

orbital rim, convergence error and head movements

Luedde exophthalmometer: Luedde exophthalmometer is a transparent plastic

millimeter ruler. Notch on scale conforms to angle of lateral orbital rim and scale
readings are from 0mm (end of notch) to 40mm. Parallax is minimized by using
scale on both sides of the rod.

Measurement of globe dystopia: Horizontal dystopia is measured by the distance

from the midline of bridge of nose to the nasal limbus, compared bilaterally. -
Vertical dystopia is measured by the superior or inferior deviation of the central
corneal reflex of the proptotic eye from a horizontal line passing through the
centre of normal eye.

figure 3: Measuremnt of vertical dystopia using millimeter scale

Limbus test of motility of Kestenbaum: This test is performed by holding a

transparent millimeter ruler horizontally in front of the cornea. In measuring
abduction, the location of the nasal limbus point is noted on the ruler in primary
position and in maximum abduction. The difference immediately gives the degree
of abduction in millimeters. Adduction is measured similarly by determining the
positions of the temporal limbus. To measure elevation and depression, hold the
ruler vertically. The examiner should test each eye with his or her own
homonymous eye. Normal values established by Kestenbaum are 10 mm for
adduction, abduction, and depression, and 5 to 7mm for elevation.

Deep palpation: For palpation of orbital tumors beyond orbital rim, the patient
will look in the opposite direction to the mass located and examiner presses his
fingertip over the surface. After this patient will look in the same direction of
orbital mass (thereby relaxing the septum), the examiners fingertip reaches beyond
orbital rim for deeper palpation.

Ptosis Work up
 Visual acuity

 Facial asymmetry

 Head posture
(Chin up position )

 Frontalis over action

 Cover test

 Lid:
1. Lid fold (mm)
2. Lid Crease (mm)
3. Scar (previous surgery)
4. compensatory lid
retraction/Pseudoptosis

 Amount of ptosis (mm)

1. MRD1
2. MRD2
3. Palpebral fissure height
 LPS excursion (mm)

 Lagophthalmos (mm)

 Lid lag

 Bell’s phenomenon (grade)

 MGJWP phenomenon (grade)

 Extraocular movements
(elevation deficit)
 Corneal sensation

 Tear film evaluation

1. TBUT
2. Schirmer’s test

 Ocular surface

 Pupil (size, reaction)

 Refraction

 Family album tomogram

 Phenylephrine test/ additional

tests (where needed)
Ptosis: Ptosis is defined as drooping of upper eyelid lower than normal
(1.5-2mm).
Amount of ptosis: The amount of ptosis can be measured by using a
millimeter scale and asking the patient to focus at a distant object with
head properly supported3. The distance between relative position of
center of upper eyelid and central pupillary reflex is measured, and
value is compared with opposite normal eyelid. Based on obtained value
ptosis is graded

Fig: Ptosis measurement using millimeter scale.

Mild: ≤2mm
Moderate: 3mm
Severe: ≥4mm
Ptosis can also be assessed by using torch light. In this method position
of eyelid in relation to pupillary border is assessed, with patient looking
at a distant object and maintaining a stable head position. Flash from
torch light should not be fall directly on eyes of patient, otherwise it may
give false values because of reflex blepherospasm and pupillary
constriction. Based on the position of eyelid ptosis is graded as
Mild: eyelid position at pupillary border
Moderate: eyelid position in between pupillary border and pupillary
reflex
Severe: eyelid bisects pupil
Bell’s Phenomenon: It is a defensive mechanism where patient’s eye
moves upwards and outwards on attempted eye closure. Bells
phenomenon is graded as good if less than one third cornea is visible,
fair if up to half of the cornea is visible, poor if more than half of cornea
is visible, reverse if eye moves up and inwards, and inverse if eye moves
down and out or inwards.
Marcus gunn jaw winking phenomenon (MGJW): MGJW is a synkinetic
movement of upper eyelid on movement of jaw in congenital ptosis resulting from
aberrant connection between motor division of trigeminal nerve controlling
masticating movement of jaw and motor division of oculomotor nerve supplying
levator palpebrae superiosus.4 MGJW is graded based of amount of eyelid
elevation as mild for ≤2mm, moderate for 3-6mm and severe for ≥ 7mm

Figure 4: MGJW ptosis

Figure 5: upper eyelid lift with jaw movement to opposite side

Figure 6: Re-enforcement test: Maximum lift of upper eyelid is assessed by
applying resistance in opposite direction of jaw movement.

Phenylephrine test: This test is done for congenital simple mild ptosis. Instill 2
drops of 2.5% phenylephrine in the inferior fornix of testing eye, wait 5 minutes,
and assess any change in the palpebral fissure and the marginal reflex distance5.
If ptotic lid is elevated, then Conjunctivo-mullers resection surgery can be
planned. If no response is observed or if elevation is not adequate, external levator
resection surgery is planned.

Contracted socket work up

 Right/ Left side

 Facial symmetry

 Bony orbit(mm)-horizontal/vertical

dimensions

 Sulcus deformity

 Palpebral aperture(mm)-

horizontal/Vertical dimensions

 Entropion/ Ectropion

 Lid/Tendon laxity/ Dystopia

 Status/size of eyeball (anophthalmic/

ophthalmic)

 Implant

 Prosthesis (surface and colour)

 Conjunctival surface

 Forniceal dimensions (mm)

a. Superior

b. Inferior

c. Lateral
 d. Medial

 Forniceal shortening/shelving

 Volume of the socket

 Volume of orbit

 Palpation of socket(implant site/mass)

 Signs of trauma (soft tissue/ bone)

Contracted socket: It is defined in simple term as any socket which is

unable to retain prosthesis6. Grading of contracted socket is as follows7
Grade 0: Socket is lined with healthy conjunctiva and has deep and
well-formed fornices
Grade I: Shallow lower fornix or shelving of the lower fornix pushing
the lower lid down and out and preventing retention of an artificial eye
Grade II: Loss of the upper and lower fornices
Grade III: Loss of the upper, lower, medial, and lateral fornices
Grade IV: Loss of all the fornices and reduction of palpebral aperture in
horizontal and vertical dimensions
Grade V: Recurrence of contraction of the socket after repeated trial of
reconstruction.
Assessment of socket volume: Upon removal of the prosthesis, the socket should
be assessed for adequacy of the superior and inferior fornices, presence of
symblepharon, integrity and state of the conjunctival lining, position of the orbital
implant, and signs of infection or inflammation. Palpation of the socket cavity can
reveal migration of and shape and size characteristics of the orbital implant, as
well as space-occupying orbital masses. If the possibility of a significant orbital
fracture or recurrent tumor exists, radiographic studies with computerized
tomography are indicated. Subjective method for assessing volume of socket is by
comparing relative depth with that of other normal eye. Objective method of
assessment is by slowly injecting drop by drop in the socket after opening the
eyelids with speculum. The amount of normal saline than can be instilled is the
volume of socket. Superior sulcus deformity and ptosis are also indicators of
volume loss.

Fornix dimensions: In healthy subjects the normal range for forniceal dimensions
are 12-16mm, 8-12mm, 4-6mm and 2-4mm for superior, inferior, lateral and
medial fornices respectively8. Measurements are taken by using a calibrated rod or
scale and asking the subject to look at a fixed object or asking him to look in
opposite direction. Inferior fornix is important among all as it supports the
prosthesis.

Prosthesis: Careful evaluation of the ocular prosthesis is important which includes

searching for protein deposits, scratches, and irregularities, aided by the use of a
magnifying loupe or slit-lamp biomicroscope. An excessively large and heavy
prosthesis may aggravate lower lid laxity and result in a dropped socket
appearance. Close interaction with an ocularist is critical, as modification or
replacement of a prosthesis can correct upper lid ptosis, superior sulcus defects,
eyelid malpositions, poor motility, and mild socket contraction in selected cases.

Entropion/Ectropion work up
Right / Left eye Upper / Lower eyelid

Visual acuity

Lid position / Grade

Pinch test
 Snap back test

Medial canthal laxity / position

Lateral canthal laxity / position

Upper/Lower lid position

Trichiasis / Distichiasis / Madarosis / Margin

keratinization

Tarsal plate

Lid / Puncta / other findings

Meibomian gland orifices

Lid retraction / sagging / ptosis / lagophthalmos

(mm)

Ocular surface / Fornices

Symblepheron / Ankyloblepheron / Others

skin scar

Other relevant findings

Entropion: Entropion is an inward turning of the lid margin and appendages such that the
pilosebaceous unit and mucocutaneous junction are directed posterior towards the cornea and
ocular surface.

Etiological classification:

1. Involutional
2. Spastic
3. Cicatricial
4. Congenital

Involutional entropion is further discussed below.

Grading of entropion (Kemp and Collin):

 Minimal- apparent migration of meibomian glands, conjunctivalization of lid margin and

lash-globe contact on up gaze.
  Moderate- apparent migration of meibomian glands, conjunctivalisation of lid margin,
lash-globe contact in primary position, thickening of tarsal plate and lid retraction.
 Severe- lid retraction causing incomplete closure, gross lid distortion, metaplastic
lashes, presence of keratin plaques

Assessment of capsulopalpabral fascia laxity : ❑Increased depth of inferior fornix

❑Diminished lower lid excursion between extreme up-gaze and down-gaze(normal- 3-4 mm)
(presence of lower lid crease on downgaze is an indirect sign of functioning lid retractors)
❑Presence of white edge of disinserted/dehiscent lower lid Retractors separated from tarsus by
a pink band of orbicularis fibers ❑On retraction of lower lid , v shaped abnormality or notching
of culde-sac at the site of dehiscence maybe seen ❑Increased fat pad height in the fornix. Pull
the lower lid margin to the level of the inferior orbital rim and compare the meniscus of
Protruding fat in each fornix

Ectropion: Ectropion is outward turning in eyelid margin.

Etiological classification:

1. Involutional
2. Spastic
3. Cicatricial
4. Congenital
5. Mechanical

Grading of ectropion:

 Mild- only punctum is everted

 Moderate- lid margin is everted and palpebral conjunctiva is visible
 Severe- fornix is also visible

Pinch Test: (Horizontal lid laxity) Pull the lower lid away from globe and measure the
distance between center of lid and ocular surface. Normal value is 2-3mm. Readings >6 mm
is considered lax.

Snap-back Test9: (Orbicularis muscle tone) Pull the lower lid away and down from the globe
for several seconds. Note the time required for it to return back to normal position. Normally
the lid resumes position without the aid of a blink. Grading is from 0 to 4(0= normal;
1=returns in 2-3 seconds; 2= returns in 4-5 seconds; 3= >5seconds but returns with a blink;
4 = Never returns)
Lateral canthal laxity9: Pull the lower lid medially from lateral canthus. Measure
displacement of the lateral canthal corner. It is graded from 0-4(0= <2mm, 1=2-4mm; 2=4-
6mm; 3=>6mm; 4= never returns to baseline even after blink)

Medial canthal laxity9: Pull the lower lid laterally from the medial canthus. Measure
displacement of the medial punctum. It is graded from 0-4 (0= <1mm; 1=≈2mm; 2=≈3mm;
3=>3mm; 4= never returns to baseline even after blink)

Eyelid tumor work up

Right/ Left eye
  Inspection
1. Site & extent – UL/LL

2. Size -Maximum/ Minimum

3. Appearance/ surface

4. Color/ Pigmentation

5. Telangiectasia

6. Overlying skin

7. Loss of lid/margin tissue

8. Palpebral conjunctiva

9. Mechanical ptosis

10. Ocular movements

11. Proptosis / Globe dystopia

 Palpation
Extent including forniceal involvement
Surface
Consistency
Margins
Fixity to underlying structures (tarsus/ bone)

 Regional spread

 Systemic evaluation

TNM Staging (8th edition)

Basal cell carcinoma is the most common malignant eyelid tumor reported in the
West and in some Asian countries like China, Singapore, Thailand and Taiwan,
whereas in India sebaceous gland carcinoma is the most common malignant eyelid
tumor10.

Sebaceous cell carcinoma: Sebaceous cell carcinoma is a malignant neoplasm of

sebaceous glands that most commonly occurs in the periorbital area. The eyelid is
the most common location of this tumor. SGC preferentially develop in the eyelids
because of the abundance of sebaceous glands in the tarsus (meibomian glands),
eyelashes (Zeis glands), and the caruncle. SGC may have varied clinical
presentations, according to their site of origin. Risk factors for developing
sebaceous cell carcinoma include older age, female sex, radiation exposure,
immunosuppression, and prolonged use of thiazide diuretics. A solitary eyelid
nodule that is firm and painless, often with a yellow color, and subcutaneous in
location is representative of sebaceous cell carcinoma. A diffuse
pseudoinflammatory pattern characterized by unilateral eyelid thickening has also
been recognized. The tumor often extends into the bulbar conjunctiva and the
corneal epithelium giving appearance of ‘unilateral blepharitis’. When the
sebaceous cell carcinoma originates from the glands of Zeis, it can present as an
ulcerated nodule or a cutaneous horn. It can be mistaken for a squamous cell
carcinoma. An irregular yellow mass in the medial canthus can represent a
sebaceous cell carcinoma involving the caruncule. Lacrimal gland involvement
often mimics a unilateral blepharoconjunctivitis. It is imperative to rule out
sebaceous cell carcinoma in cases of unilateral blepharitis or conjunctivitis or in
cases unresponsive to appropriate treatment.

Basal cell carcinoma: Basal cell carcinomas originate as a neoplastic

transformation of the basal cells of the epidermis. BCC occur most frequently on
the lower eyelid, followed in order of frequency by the medial canthus, upper
eyelid and lateral canthus. Clinically basal cell carcinomas are divided into six
subtypes: nodular, superficial, micro nodular, infiltrative, morpheaform or
sclerosing, and fibroepithelioma of pinkus. Nodular basal cell carcinomas are the
most common type representing greater than 60% of all tumors. A nodular BCC
typically begins as a small translucent nodule or papule, often evolving into the
characteristic lesion composed of a central ulcerated crater with pearly rolled
margins. The less-common diffuse morpheaform or sclerosing type typically
appears as a white-pink to yellow plaque with indistinct clinical margins and scar
like appearance. Hyperpigmentation of either type of lesion may lead to confusion
with malignant melanoma.

Squamous cell carcinoma: Squamous cell carcinoma is a common non-

melanomatous skin cancer which occurs in locations lined by superficial
epithelium. Actinic keratosis, Bowen's disease, and radiation dermatoses are all
 precursors to the development of squamous cell carcinoma. Although actinic
keratosis are considered precancerous lesions, < 1% go on to become SCC.
Squamous cell carcinomas, like BCCs, occur most frequently on the lower eyelid.
SCCs often appear as painless nodular or plaque-like lesions with irregular rolled
edges, chronic scaling with roughened patches, fissuring of the skin, pearly
borders, telangiectasia and central ulceration.

Malignant melanoma: Malignant melanoma of the eyelid skin arises from the
malignant proliferation of melanocytes. It can arise de novo or from a pre-existing
nevus. Malignant melanoma commonly presents on chronically sun exposed skin of
middle-aged and elderly individuals. It usually appears as a > 1 cm pigmented
patch, often with color variegation including tan, light brown, dark brown, and
black. It may exhibit a darker network-like pigmentation. It is slowly expansile.

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