How do you safely evert an eyelid?

How to Safely Evert an Eyelid

Eyelid eversion should be performed using a silicone rubber everter or your index finger placed at the top of the tarsal plate, as these methods are most comfortable for patients while exposing adequate palpebral conjunctiva for examination. 1

Technique Selection

The optimal eversion technique depends on balancing patient comfort, speed, and visualization of the tarsal conjunctiva:

• Silicone rubber everter (finger-shaped substitute) placed at the top of the tarsal plate is the preferred method, as it is most comfortable for patients, quick to perform, and exposes the greatest area of palpebral conjunctiva 1
• Clinician's index finger alone provides similar comfort to the silicone everter and is acceptable when specialized equipment is unavailable 1
• Cotton bud techniques are less comfortable and should be avoided when possible, particularly off-center placement or using the wooden end of the cotton bud 1

Step-by-Step Procedure

Preparation

• Position the patient comfortably with adequate lighting for visualization 2
• Explain the procedure to reduce anxiety and ensure cooperation 1

Eversion Technique

• Ask the patient to look downward 1
• Grasp the eyelashes of the upper eyelid gently between your thumb and index finger 1
• Place your silicone everter or index finger horizontally at the superior border of the tarsal plate (approximately 10mm above the eyelid margin) 1
• Apply gentle downward pressure with the everter/finger while simultaneously pulling the eyelid margin upward and outward 1
• Fold the eyelid back over the everter/finger to expose the tarsal conjunctiva 1

Clinical Context for Eyelid Eversion

When Eversion is Essential

• Daily examination during acute phase of Stevens-Johnson syndrome/toxic epidermal necrolysis to assess tarsal conjunctiva for inflammation, fibrosis, and signs of allergy 2
• Routine dry eye evaluation to document tarsal conjunctival status including inflammation, papillary reaction, follicle enlargement, keratinization, subepithelial fibrosis, and scarring 2
• Contact lens aftercare to inspect the palpebral conjunctiva for complications 1
• Blepharitis assessment to evaluate posterior eyelid margin abnormalities and meibomian gland dysfunction 2, 3

What to Examine After Eversion

• Assess integrity of tarsal conjunctiva using topical fluorescein to stain epithelial loss 2
• Remove pseudomembranes if present 2
• Break down conjunctival adhesions 2
• Evaluate for mucous threads, scarring, erythema, papillary reaction, follicle enlargement, keratinization, subepithelial fibrosis, foreshortening, and symblepharon 2

Important Caveats

• Repeatability: Eyelid eversion produces consistent results when repeated, so do not hesitate to re-examine if initial visualization is inadequate 1
• Patient comfort: The technique you choose significantly impacts patient tolerance—using fingers or silicone everters causes less discomfort than cotton bud methods 1
• Avoid aggressive manipulation in patients with neurotrophic corneas to prevent corneal epithelial injury 4
• Time efficiency: The wooden end of a cotton bud is fastest but least comfortable; silicone everters provide the best balance of speed and comfort 1