Other Tests
See the list below:
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Snap-back test
Pull lower lid away and down from globe for several seconds and wait to see how long before it returns to original position without the patient blinking (if it does at all). See the image below.
This test result gives a good idea of relative lower lid laxity. In normal lids, it should spring back into original position immediately; the longer it takes, the more laxity is present. See the image below.
Grade 0-IV (0 = normal, IV = severe laxity): This scale is subjective and comes with clinical experience.
Grade 0 - normal lid that returns to position immediately on release
Grade IV - never returns to position and continues to hang down in frank ectropion after the snap-back test
Grade I - approximately 2-3 sec
Grade II - 4-5 sec
Grade III - >5 sec but does return to position with blinking
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Medial canthal laxity test
Pull lower lid laterally away from medial canthus and measure displacement of medial punctum; the greater the distance, the more the laxity.
Normally, displacement should be only 0-1 mm.
Grade 0-IV (0 = normal, IV = severe laxity): This test uses the same scale as the snap-back test; it is also subjective and based on clinical experience.
Grade I - approximately 2 mm displacement
Grade II - approximately 3 mm
Grade III - >3 mm
Grade IV - does not return to baseline
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Lateral canthal laxity test
Pull lower lid medially away from lateral canthus and measure displacement of lateral canthal corner; the greater the distance, the more the laxity.
Normally, displacement should be only 0-2 mm (grade 0).
Grade 0-IV (0 = normal, IV = severe laxity): This test uses the same scale as tests above.
Grade I - 2-4 mm
Grade II - 4-6 mm
Grade III - >6 mm
Grade IV - III and does not return to baseline even after blinking
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Schirmer test: Having an idea of how dry the eyes are is helpful, as ectropion is only one of several conditions in the differential of epiphora.
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Fluorescein test of cornea: Perform this test as a baseline for the same reasons one does the Schirmer test.
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Irrigation of lacrimal system: If the system is blocked, a dacryocystorhinostomy alone or in combination with an ectropion procedure would be better than treating the ectropion alone.
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Slit lamp examination: Specifically check corneal status and evidence of dryness. Also check for evidence of lagophthalmos.
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Presence or absence of Bell phenomenon: Patient is told to attempt closure of eyes while examiner is holding lids open; if eye moves up, positive Bell is present.
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Check status of seventh nerve.
With lower motor neuron seventh nerve palsy (eg, Bell palsy), the ipsilateral brow and lower facial musculature are weak. With an upper motor neuron seventh nerve palsy, brow elevation is relatively spared from bilateral innervation of the upper face.
In patients with suspected facial nerve palsy, test for orbicularis oris dysfunction by asking the patient to show his or her teeth rather than smile. Compare the elevation of the angles of the lips; there is often ptosis of the lateral lip on the affected side.
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Ectropion with keratinization of the lower lid.
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The snap-back test.
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Lower lid laxity obvious after snap-back test.
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Preparing the lateral tarsal strip.
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The 4-0 Vicryl suture is paced through the tarsal strip in a horizontal mattress fashion.
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The suture is tied to the periosteum of the lateral orbital rim and tightened.
