aka Ophthalmology Befuddler 005
A man presents with a diffusely red eye and a problem with his eyelids. You resist the urge to send out a ‘Trauma Call’ and start wracking your brains for everything you know about eyelid disorders.
Q1. What is the differential diagnosis of an essentially painless, but red, eye?
This can be caused by conjunctivitis, but there is usually at least some degree of discomfort. Otherwise the main causes are eyelid disorders such as:
- blepharitis, canaliculitis, dacryocystitis,
- ectropion and entropion
- trichiasis (malaligned eyelashes that irritate the eye)
- eyelid lesions, such as chalazion/hordeolum and malignancies.
Q2. What is blepharitis and what are the symptoms?
Inflammation of the eyelids characterised by:
- itching, burning, mild pain or a foreign body sensation
- crusting around the eyes on awakening.
Blepharitis usually refers to anterior blepharitis, which affects the anterior part of the eye lid and is often related to staphylococcal infection or seborrheic dermatitis. Posterior blepharitis is also known as meibomitis.
Q3. What are the examination findings of blepharitis?
The key finding is:
Thick red and crusted eyelid margins with prominent blood vessels
Other findings include:
- coexistent meibomitis — inspissated oil glands at the eyelid margins
- Conjunctival injection, swollen eyelids, and mild mucous discharge may be present.
- Superficial punctate keratopathy (SPK) or even corneal infiltrates are present in some cases.
Check out this video from RootAtlas.com demonstrating a a nasty case of meibomitis.
Q4. How is blepharitis managed?
- regular lid hygiene — e.g. scrub the eyelid margins twice a day with mild shampoo (like Johnson’s baby shampoo) on a cotton-tipped applicator or a wash cloth.
- Warm compresses for 15 minutes up to qid
- use artificial tears for coexistant dry eyes
- consider chloramphenicol 1% eye ointment topically to the lid margins, once or twice daily until clinically resolved (efficacy of topical antibiotics in blepharitis is uncertain).
- unresponsive meibomitis or ocular rosacea may require long courses (e.g. months) of oral doxycycline (has an anti-inflammatory effect) and cyclosporin eye drops.
On rare occasions the condition is intractable because there is sebaceous gland carcinoma of the eyelid.
Arrange ophthalmology follow up for about 1 month after treatment is started — blepharitis tends be a chronic problem.
Q5. How does the timing of symptoms help distinguish dry eye syndrome from blepharitis?
In blepharitis, symptoms and crusting are usually worse at the start of the day. In dry-eye syndrome symptoms are usually worse later in the day.
Q6. What is entropion?
Entropion occurs when a lid turns inward and is at risk of causing a corneal abrasion.
Q7. What are the features of entropion on history and examination?
- ocular irritation, tearing, redness, foreign body sensation.
- consider the causes:
- involutional (aging)
- cicatrical (scarring from trauma, surgery or chemical burns)
- spastic (e.g. ocular irritation)
- Slit lamp — use fluorescein to detect conjunctival injection, SPK, and a corneal abrasion.
Q8. How should an entropion be managed?
- If the cornea is intact, the eye should be lubricated and the patient referred to an ophthalmologist.
- Start topical antibiotics if SPK is present.
- If there is a corneal defect the eyelid should be taped back away from the cornea, the corneal defect is managed as a corneal abrasion, and referral to ophthalmology made. Surgery may be needed for definitive treatment.
Q9. What is ectropion, and how does it differ to entropion?
Ectropion is out-turning of an eyelid that can result in exposure keratopathy. But otherwise the treatment and causes are similar to entropion, with the addition of these causes:
- paralytic — e.g. CN7 palsy
- mechanical — e.g. orbital fat herniation or a tumor
Q10. What is canaliculitis?
Tearing, a red eye, and mild tenderness over the nasal aspect of the lower or upper eyelid due to an inflamed of the canalicus. A key feature is an inflamed punctum, from which there may be mucopurulent discharge.
What’s a punctum you ask? Check out this short video at Rootatlas.com to find out.
Q11. How is canaliculitis treated?
Send a swab of the punctal discharge to the lab as causes include Actinomyces israeli, bacteria, fungi and viruses as well retained mucous plugs.
- removal of concretions
- application of warm compresses
- topical antibiotics (may need to be changed following cultures)
- arrange ophthalmology follow up in a week. Elective canaliculotomy may be required.
Q12. What is dacryocystitis?
Painful swelling of the lacrimal sac in the innermost aspect of the lower eyelid. It is usually related to nasolacrimal duct obstruction and secondary infection by staphylococci, streptococci and diphtheriae.
Q13. How is dacryocystitis managed?
- Send off a swab to the lab for MCS.
- Administer oral antibiotics:
flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly
(cephalexin is an alternative)
- Consider IV antibiotics (e.g. cephazolin) if febrile and acutely ill.
- Treat with analgesia and warm compresses.
- Refer to ophthalmology — a pointing abscess may be incised and drained. When chronic, surgery may be required.
- Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
- Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com]
- NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide, 2007. [link to free pdf]
- Therapeutic Guidelines (Australia) [subscription required]