How to Examine and Treat Ocular Adnexa: A Step-by-Step Clinical Guide

When assessing ophthalmic signs related to the adnexa, you’re evaluating the structures around the eye, not the eyeball itself. These include:

• Eyelids

• Lacrimal apparatus

• Conjunctiva

• Orbital tissues

This is crucial in both general eye exams and in identifying infections, trauma, tumors, or systemic diseases.

👁️‍🗨️ What Are the Ocular Adnexa?

🔍 Ophthalmic Signs: Adnexa Exam Overview

1. Eyelids

Check for:

• Ptosis – drooping of the eyelid (e.g., Horner’s syndrome, oculomotor palsy)

• Lid retraction – seen in thyroid eye disease

• Ectropion – lid turns outward

• Entropion – lid turns inward (can cause lashes to scratch cornea)

• Edema or swelling – common in infection or trauma

• Lid masses – e.g., chalazion, hordeolum (stye), basal cell carcinoma

📌Signs:

• Redness

• Crusting

• Incomplete closure (lagophthalmos)

• Eyelid spasm (blepharospasm)

2. Lacrimal System

Inspect:

• Lacrimal gland (upper outer lid) for swelling or tenderness (e.g., dacryoadenitis)

• Tear drainage system for:

  • Epiphora – excessive tearing (obstruction)

  • Discharge or pus at puncta (suggests dacryocystitis)

  • Pressure on lacrimal sac – look for regurgitation of pus

3. Conjunctiva

Observe both:

• Palpebral conjunctiva (lining eyelids)

• Bulbar conjunctiva (covering sclera)

Look for:

• Injection (redness) – general or localized

• Chemosis – conjunctival edema (allergy, trauma, infection)

• Pseudomembranes – suggest viral/bacterial conjunctivitis

• Foreign bodies

• Subconjunctival hemorrhage – bright red patch (benign or traumatic)

4. Orbital Signs

Observe for:

• Proptosis – eye pushed forward (thyroid eye disease, tumor, orbital cellulitis)

• Enophthalmos – eye sunken in (orbital fracture)

• Periorbital swelling or bruising (trauma or infection)

• Eye movement limitation – can indicate mass or muscle entrapment

• Pain on movement – orbital cellulitis

📌 Check for Relative Afferent Pupillary Defect (RAPD) if optic nerve is involved.

5. Palpation and Special Tests

• Gently palpate orbital rim for step-offs (trauma)

• Palpate lacrimal sac for tenderness/discharge

• Use fluorescein to detect foreign bodies or corneal abrasion

• Test eyelid eversion to inspect upper conjunctiva

🧠 Clinical Conditions with Adnexal Signs

🧪 Optional Diagnostic Tools

• Slit lamp exam – for closer look at lids/conjunctiva

• CT orbit – if abscess, trauma, or mass is suspected

• Tear break-up time or Schirmer’s test – for dry eye

• Culture – of discharge if infection suspected

✅ Summary: Key Signs in Adnexal Examination

🩺 Treatment of Common Ocular Adnexal Conditions

1. Blepharitis

• Management: Warm compresses (15 minutes, twice daily) to loosen crusts and massage the eyelids to express meibomian gland secretions.

• Medications: Topical antibiotics like bacitracin or erythromycin ointment may be applied to the eyelid margin.

• Hygiene: Regular eyelid scrubs with diluted baby shampoo or commercial lid cleansers to remove debris and bacteria.

2. Chalazion

• Initial Treatment: Warm compresses (15 minutes, four times daily) to promote drainage.

• If Persistent: Incision and drainage may be necessary if the chalazion persists after four weeks of medical therapy.

• Steroid Injection: In some cases, a corticosteroid injection may be used to reduce inflammation.

3. Hordeolum (Stye)

• Acute Management: Warm compresses (15 minutes, four times daily) to promote drainage.

• Antibiotics: Topical antibiotics like bacitracin or erythromycin ointment may be applied.

• If Non-Resolving: Incision and drainage may be required for persistent lesions.

4. Dacryocystitis

• Acute Cases: Oral antibiotics (e.g., amoxicillin-clavulanate) to treat infection.

• Chronic Cases: Surgical intervention, such as dacryocystorhinostomy, may be necessary to relieve obstruction.

5. Conjunctivitis

• Bacterial: Topical antibiotics (e.g., ciprofloxacin 0.3% eye drops) are prescribed.

• Viral: Typically self-limited; supportive care is provided.

• Allergic: Antihistamine eye drops (e.g., olopatadine) and avoiding allergens.

6. Carcinoma in Situ of Ocular Adnexa

• Surgical Excision: Primary treatment involves complete surgical removal of the neoplastic tissue.

• Topical Chemotherapy: Agents like 5-fluorouracil or mitomycin C may be used for superficial lesions.

• Photodynamic Therapy: Utilized for patients who are not candidates for surgery.

🎥 Educational Video: Ocular Adnexa Examination

For a comprehensive understanding and visual demonstration of ocular adnexal examination techniques, you can watch the following video:

This video provides step-by-step guidance on examining the eyelids, lacrimal apparatus, and surrounding structures, which is essential for diagnosing adnexal conditions.