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    Why you should add upper lid eversion to your comprehensive exam


    LWE is a critical diagnostic sign in dry eye disease and one we monitor over time. LWE may present with different severity (See Figures 1-4). Without UEE, this cannot be seen.Figure 3. Lid wiper epitheliopathy (LWE)

    Identify floppy eyelid syndrome

    Everting the upper eyelid is also critical in identifying floppy eyelid syndrome (FES). Individuals with FES may present with general ocular discomfort very similar to a dry eye patient. In more severe forms, patients may come in with acute conjunctivitis, including conjunctival hyperemia, corneal staining, and a papillary response on the palpebral conjunctiva.

    Related: 3 tips to better fit keratocones with sclerals

    FES patients may have lower levels of elastin in their upper eyelids, causing upper eyelids that more easily evert than in the normal individual. It is very evident in these individuals to identify FES upon attempted UEE. It is critical to rule FES out if you suspect dry eye may be causing the symptoms in order for these patients to be treated properly. Typical defense may include ocular lubricants, some form of eye shield in the evening, and in more severe forms an upper eyelid resection.Figure 4. Lid wiper epitheliopathy (LWE)

    FES and sleep apnea

    FES is critical to identify in patients because of its association with sleep apnea. Often patients forget to report sleep apnea upon initial medical history questioning.  When we identify FES and ask about obstructive sleep apnea (OSA), these patients tend to admit to sleep apnea treatment.

    Knowing if a patient has OSA is important because they may be prone to FES. OSA patients  are frequently treated with continuous positive airway pressure through masks worn in the evening.1

    For those patients not currently diagnosed with sleep apnea, it is important to educate them about the association of FES with OSA and potentially further investigate his health with his physician.

    Everting unveils upper eyelid findings

    Everting the upper eyelid is critical to identifying several conditions. If you do not evert the eyelid, it may be difficult to appreciate the influence of the upper eyelids on the ocular surface and the link with certain systemic conditions.



    1. McNab, AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthal Plast Reconstr Surg. 1997 Jun;13(2):98-114.

    Read more Optometry Times blogs here

    Mile Brujic, OD, FAAO
    Dr. Mile Brujic practices in Bowling Green, OH. He also owns Optometric Insights, a service providing career coaching to optometrists.
    David Kading, OD, FAAO, FCLSA
    Dr. Kading owns a two-location, three-doctor practice in Seattle. He specializes in dry eye and contact lenses with an emphasis on ...


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