Upper lid eversion is the more difficult, often requiring cooperation or restraint, because the examiner needs to use both hands After restraint, grasp the eyelashes and free margin of the upper lid between the index finger and the thumb Ask the child to look down at the floor if he/she will cooperate Draw the eyelid downward as shown in Figure 130.15A Place a clean cotton-tipped swab across the superior tarsal margin, as shown in Figure 130.15B In one motion, move the swab slightly downward and pull the eyelid slightly upward This maneuver should bend the eyelid slightly upward and backward and expose the palpebral surface, as shown in Figure 130.15C To restore the lid to its usual position, lift the swab slightly while maintaining pressure along the upper lid margin, and turn the thumb and index finger downward Lower Lid Place a thumb or finger at the base of the lower lid and gently retract it in a caudal and posterior direction while the child looks upward ( Fig 130.15D ) IRRIGATION OF THE CONJUNCTIVA Indications Presence of a foreign body or caustic substance on the cornea or conjunctiva Complications Subconjunctival hemorrhage Corneal abrasion Conjunctival erythema Procedure Place the child supine over a large sink or basin, as shown in Figure 130.16 To restrain an uncooperative child, two assistants are necessary The person holding the head should wear a gown and may use gauze under each thumb to improve grip and help keep the eyelids open For foreign-body removal, where delay of a few minutes will not lead to further injury, place one to two drops of topical ophthalmic anesthetic on the conjunctiva Allow normal saline solution (between room and body temperature) to flow through a set of IV tubing Drip the fluid rapidly into the conjunctival sac Irrigate for a minimum of minutes for acid using at least L Irrigate for 20 minutes for alkali or unknown substances using at least L Tap water at room temperature is an acceptable alternative for irrigation fluid, especially if it can be done immediately, such as in a home or office setting Irrigation should continue until a neutral pH is achieved measured using pH paper applied to the conjunctiva (pH testing is generally repeated several times over 30 minutes to ensure the pH remains neutral) A Morgan Lens is a commercially available device that can be inserted like a contact lens to facilitate irrigation of the eye FIGURE 130.15 Eversion of the eyelid FIGURE 130.16 Irrigation of the conjunctiva After irrigation, the eye should be carefully examined for corneal and conjunctival integrity, including staining with fluorescein dye EYELID RETRACTION Indications Identification and removal of a foreign body Enable examination of the anterior surface of the eye, cul de sac, and palpebral conjunctiva, especially in the uncooperative patient or when concern for traumatic rupture of the globe exists Complications Contusion of lid/globe Corneal abrasion Procedure Place one finger on the orbital rim and gently but firmly roll the finger to gather the elastic tissue at the lid either upward (for the superior orbital rim) or downward (inferior rim) ( Fig 130.17 ) This maneuver overcomes the orbicularis oculi muscle and makes complete forced eyelid closure extremely difficult for the uncooperative patient Several eye lid retractors are also available The most useful for the emergency physician is the Desmarres retractor An alternative is the Eyegenie eyelid retractor which has the advantage of having both upper and lower lid retractors on a single instrument Place a drop of topical anesthetic on the bulbar conjunctiva, and then slip the blade of the retractor under the lid margin and exert gentle traction upward and/or downward as indicated, as well as away from the globe The Desmarres retractor in Figure 130.17 is demonstrating both eyelid eversion and gentle retraction If only one retractor is to be used, it is most helpful to retract the upper eyelid, which often overhangs the lower lid when both are swollen ... the uncooperative patient Several eye lid retractors are also available The most useful for the emergency physician is the Desmarres retractor An alternative is the Eyegenie eyelid retractor which