How is double eversion of the upper eyelid performed?

How to Perform Double Eversion of the Upper Eyelid

Double eversion of the upper eyelid is performed by first everting the lid in standard fashion, then re-everting the already-everted tarsal conjunctiva to expose the superior fornix and its contents.

Technique

Standard (Single) Eversion - First Step

1. Ask the patient to look down while keeping both eyes open
2. Grasp the eyelashes at the central portion of the upper lid between your thumb and index finger
3. Pull the lid gently downward and outward to disengage it from the globe
4. Place your other thumb or index finger (or a cotton-tipped applicator) on the skin overlying the superior border of the tarsal plate (approximately 10mm above the lid margin)
5. Apply gentle downward pressure with the finger/applicator while simultaneously pulling the lashes upward and over your pressing digit
6. The lid will evert, exposing the tarsal conjunctiva 1

Double Eversion - Second Step

Once the lid is everted in standard fashion:

1. Maintain the first eversion by holding the everted lid margin
2. Apply additional upward traction on the already-everted lid margin
3. Use your other hand to apply pressure at the superior edge of the now-visible tarsus
4. Push upward and posteriorly to fold the tarsal conjunctiva back upon itself
5. This exposes the superior fornix, allowing visualization of material that may be hidden in the deep fornix (such as the mucopurulent coagulum seen in giant fornix syndrome) 2

Clinical Context and Indications

Double eversion is particularly valuable for:

• Giant fornix syndrome: Reveals enlarged superior fornix with coagulum of mucopurulent material in elderly patients 2
• Floppy eyelid syndrome: Demonstrates the easily everted upper lid with diffuse papillary reaction 2, 3
• Foreign body detection: Exposes material lodged deep in the superior fornix
• Giant papillary conjunctivitis: Better visualization of superior tarsal papillary hypertrophy 2

Key Technical Points

Comfort optimization: Using your finger alone or a silicone everter at the top of the tarsal plate provides the most comfortable technique while exposing the greatest area 1. The wooden end of cotton-tipped applicators or off-center placement causes more discomfort and should be avoided.

Patient positioning: Have the patient look downward throughout the procedure to relax the levator muscle and facilitate eversion.

Gentle technique: Excessive force or repeated manipulation can cause mechanical irritation. The procedure should be smooth and deliberate 4.

Common Pitfalls

• Inadequate initial eversion: If the first eversion is incomplete, the second eversion will be impossible
• Patient looking up: This tenses the levator and prevents proper eversion
• Excessive force: Can cause corneal abrasion or patient discomfort
• Inadequate superior fornix exposure: Failing to push far enough posteriorly during the second eversion misses the diagnostic benefit

The technique is reproducible with consistent results when performed correctly 1.