The eyelids should be inspected to make sure that the lid margins and puncta are correctly
aligned against the globe and that there are no ingrowing lashes. Early basal cell carcinomas (also known as rodent ulcers) on eyelid skin can easily be missed, especially if obscured by cosmetics. The presence of ptosis should be noted and the ocular movements assessed by asking the patient to follow a finger upwards, downwards and to each side. Palpation of the skin around the eyes can reveal an orbital tumour or swollen lacrimal sac. Palpation with the end of a glass rod is sometimes useful to find points of tenderness when the lid is diffusely swollen. Such tenderness can indicate a primary infection of a lash root or the lacrimal sac. Both surfaces of the eyelids should be examined. The inside of the lower lid can easily be inspected by pulling down the skin of the lid with the index finger. The upper lid can be everted by asking the patient to look down, grasping the lashes gently between finger and thumb, and rolling the lid margins upwards and forwards over a cotton-wool bud or glass rod. The lid will usually remain in this everted position until the patient is asked to look up. Foreign bodies quite often lodge themselves under the upper lid and they can only be removed by this means. As a general rule, if a patient complains that there is something in his eye, there usually is, and if you find nothing, it is necessary to look again more closely or refer the patient for microscopic examination. A feeling of grittiness can result from inflammation of the conjunctiva and this might be accompanied by evidence of purulent discharge in the lashes. The presence of tear overflow and excoriation of the skin in the outer canthus should also be noted.
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