Eye care practitioners should not overlook information gleaned by a careful external and slit lamp examination. Carefully evaluating lid and lash position, assessing lid congruity to the globe and establishing features of excursion including frequency are key elements of any thorough exam of the adnexa.

The lids serve a dual function as it relates to blinking and tear film interaction. First, by blinking, the upper lid spreads the tear film over the cornea, and second, blinking empties the conjunctival sac by its pumping effect on the lacrimal sac.1 This is why an effective blink is critically essential to contact lens wearing success.

Never Ignore These Findings
Eyelashes (cilia) are expected to project from the anterior rounded border of the lid; the upper lid lashes are longer and curl upward, while the lower lid lashes curl downward and serve a vital protective purpose.1 Lashes are stiff hairs arranged in two to three rows. Missing (madarosis) or misdirected lashes (trichiasis) can result in notable pathology; the cornea can even be significantly violated. Loss of lashes and a discoloration of lashes can be diagnostic, as typically they should not grey with age. A full range of causes is responsible for lash loss—including certain medications, surgery, trauma, radiation and chemotherapy or burns, infection/inflammation and other medical conditions, such as alopecia and endocrine dysfunctions.2

A focal loss with surrounding lid surface changes may signal early lid cancer. Another cause of diffuse loss of lashes is trichotilomania, or obsessive, self-inflicted pulling of lashes, which requires a psychological consult. Additionally, there may be a chronic blepharitis from an infection/inflammation causing a loss of lashes. Lash direction and position can also be helpful in diagnosing assorted conditions, such as eyelash ptosis (floppy eyelid syndrome) and chronic rubbing in allergy patients when they are curled in an unusual position. Be certain to look closely at the base of the lash for collarets that may point to Demodex infestation.

When looking for signs of blepharitis, exert gentle pressure to the lid; by doing this both the contribution of the meibomian glands quality and quantity of oil gland secretion can be assessed. Oil gland pathology can wreak havoc on any patient, especially one who wears contact lenses. Many of the patients who suffer from meibomian gland disease are symptomatic in the morning because there is little tear production and little to no lid excursion. Depending on the meibom excreted, a “toxic” tear film may be prevalent in lens wearers. Biphasic symptomatology is also possible in patients who have an additional aqueous deficiency. Evaporative dry eye is much more common and might explain common failures with topical cyclosporine use. Keep in mind that lid disease can be greatly exacerbated in patients who also suffer from ocular allergies.

Lid Treatment
Conventional therapy can be effective in restoring a stable tear film and lid effectiveness with warm compresses to decompress, proper lid and face hygiene and topical or oral therapeutics (and nutraceuticals such as fish oil). Another way to treat posterior blepharitis is by using the Maskin Meibomian Gland Intraductal Probes (Rhein Medical), which are designed to re-establish ductal patency for improvement of symptoms, such as reduced lid tenderness.3 The probes are placed 2mm to 4mm into the gland after breaking through the fibro-vascular membrane that forms over the gland.

Keep Your Guard Up
Thorough evaluation of the lids and lashes may detect underlying pathology, such as eyelid cancers or even a floppy eyelid that might impact longevity if it’s associated with an undiagnosed obstructive sleep apnea. We are on the frontline of healthcare, which means that we must provide quality care to every patient, even when they are in our chair for just a seemingly routine contact lens evaluation.  

1.  Warwick R. Eugene Wolff’s Anatomy of the Eye and Orbit. W.B. Saunders and Co. Philadelphia. 1976.183-6.
2. Malik KJ, Lee MS, Park DJ, Harrison AR. Lash ptosis in congenital and acquired blepharoptosis. Arch Ophthalmol. 2007 Dec;125(12):1613-5.
3. Maskin SL. Intraductal meibomian gland probing. Available at: http://eyetube.net/videos/default.asp?rederr. (Accessed February 2010).