When the eyelids or periorbital tissue is edematous or the patient refuses to voluntarily open the eyelids, proper examination can be difficult The techniques described in Chapter 114 Ocular Trauma for opening the traumatized eye may be useful Warm compress can be used to gently loosen crust or discharge if present When there is mild to moderate swelling, the examiner can place his/her thumbs on the supraorbital and infraorbital ridges and gently apply pressure against the underlying bone while pulling fingers (and thus the eyelids) away from each other A Desmarres retractor can be helpful to control the upper eyelid and can also be applied simultaneously to the lower eyelids ( Fig 123.3A ) Commercially available speculums, when used in association with a topical anesthetic, are another painless and efficient way of opening the eyelids ( Fig 123.3B ) Importantly, when refusal to open an eye is secondary to pain (as with a corneal abrasion) instillation of topical anesthetic prior to examination will often lead to spontaneous eye opening In infants, the eyelids may be separated using cotton swabs The swabs should be placed at the midbody of the upper and lower eyelids As they are separated, pressure should be applied down against the eyelid and the swab should be rotated inward toward the eyelashes This will keep the eyelids in place so they not spontaneously evert and further obstruct the examiner’s view The cotton swab technique should not be used in patients being evaluated for eye trauma because pressure on the eyeball from this technique could cause further injury (see Chapter 114 Ocular Trauma ) Instillation of Eye Drops It may be necessary to instill certain eye drops to complete the eye examination (e.g., topical anesthetics, dilating drops) Instillation of eye drops can sometimes be difficult because of swollen eyelids or patient noncompliance Ophthalmic solutions are designed for a one-drop dose Drops are most efficiently delivered by pulling down the lower eyelid and placing the drop in the inferior fornix In patients who are extremely resistant, forced eyelid opening is needed to expose just a small strip of palpebral conjunctiva The eyeball itself does not need to be visualized An alternative technique involves placing the eye drop in the sulcus between the medial canthus and the side of the bridge of the nose while the patient is in the supine position Every child must eventually open his or her eyes and when this happens the eye drop will naturally flow onto the conjunctiva Topical anesthetics may be necessary to complete some parts of the examination, especially in the patient with significant pain Topical anesthetics should never be prescribed for outpatient use These are strictly diagnostic agents Prolonged use of topical anesthetics may result in corneal ulceration