There are two situations when we particularly need to open the lid. The first is to look for a foreign body. The lower fornix is easy to visualize. The upper fornix can not be fully visualized. Double lid eversion is recommended, which basically means taking retractors and flipping the tarsal plate upward. This is done most easily with the patient looking down. A q-tip can be used instead, with fingers holding the lashes. This still does not allow complete visualization, and some recommend sweeping the upper fornix to sample for the foreign body. However, this technique would only work if the foreign body has more avidity for the q-tip than the conjunctivae, which is wishful thinking. If there is doubt, have the patient follow-up with the opthalmologist.
The second situation is chemosis or swelling, particularly in trauma. You pull the lids away and edema rolls over the eye. What do you do next?
Cleaning the skin might allow a better grip. The ideal method is the Desmarre eyelid retractor, but it is rarely found in the ED. It is a metal non-sharp hook that pulls the entire lid away. They can be made by bending the curved end of a paper clip to about 90-180 degrees. Just make sure it is not one of those flaking paperclips that could leave a foreign body in the eye. This should allow you to at least examine acuity, pupils, and the anterior chamber.
Take Home Points:
Clean the eyelid grease for a better grip
Use a Desmarre retractor or modified paperclip if necessary,