Blepharitis Quiz

Blepharitis

• Inflammation of eyelid margins, chronic and can be recurrent
• Anterior, Posterior, and Mixed lid margin disease
• Anterior: bacterial colonization (mostly staphylococcal), associated with seborrheic dermatitis (disorder of ciliary glands)
• Posterior: meibomian gland dysfunction, retention of secretions, blockage of meibomian glands, direct bacterial colonization, immune-mediated damage, bacterial toxins and enzymes
• Symptoms: ocular discomfort, burning, itching, soreness, mild photophobia, blurred vision, and intolerance to contact lenses. Signs of aqueous tear deficiency, lid margin hyperemia, swelling, crusting, loss of lashes, marginal keratitis, mild papillary conjunctivitis, oily/greasy deposits on lid margins

Complications of Blepharitis

• Dry eyes
• Conjunctivitis
• Chalazion formation
• Trichiasis
• Ectropian
• Entropian
• Corneal disease: punctate epithelial erosion, marginal infiltrates, recurrent erosions, marginal ulcers, pannus, keratitis, contact lens intolerance

Treatment

• Lid hygiene: cleaning lids with cotton buds, flannel, baby shampoo, or bicarbonate solutions, use of cleaning wipes, avoid cosmetics, reduce to once daily when symptoms improve
• Warm compresses: 2x daily for 10 minutes
• Ocular lubricants: symptomatic relief from dry eyes, trichiasis, and entropian
• Topical antibiotics: chloramphenicol (2x daily after deposit removal for marked lid infection)
• Oral tetracyclines: if not responding to lid hygiene, especially in patients with acne rosacea
• Topical steroids: reserved for severe cases or complications with marginal keratitis

Hordeolum (Stye)

• Localized infection/inflammation of eyelid margin
• External: involves eyelash follicle and associated glands, presents as a tender, inflamed swelling on margin
• Internal: involves meibomian glands within tarsal plate, more painful, may point towards conjunctiva or skin
• Staphylococcus Aureus infection implicated
• Symptoms: lid erythema, oedema, pre-septal cellulitis, secondary conjunctivitis
• Management: warm compress, removal of infected eyelash, topical antibiotics (chloramphenicol for recurrent lesions), referral to GP for fever or tender preauricular lymph nodes or pre-septal cellulitis

Trichiasis

• Misdirection of eyelashes towards the globe
• Different to pseudotrichiasis (eyelashes turn inwards due to entropian)
• Causes: aging, congenital, scarring of the posterior lid lamella, blepharitis, epiblepharon, past herpes zoster ophthalmicus infection, trachoma, ocular cicatrical pemphigoid, Stevens Johnson syndrome, vernal keratoconjunctivitis, and chemical burns
• Management of the offending eyelash, tackling underlying conditions, use of therapeutic contact lenses, ocular lubricants

Trachoma

• Infection with Chlamydia Trachomatis
• Begins slowly as conjunctivitis, leads to tarsal conjunctival scarring, distorts upper tarsal plate, causes entropian and trichiasis, causing eye ulcers and possible blindness (in severe cases)

Entropian

• Inversion of eyelid, lid margin turned inward toward the globe (Involutional, Cicatrical, Spastic, Congenital)
• Involutional: age-related, typically lower lid, F > M
• Cicatrical: scarring or contraction of tissue, pulls lid margin inward due to trauma, chemical burns, infections, etc.
• Spastic: results from oculomotor issues or issues with the nerves controlling the eyelid motion
• Congenital: from developmental issues of the lower lid retractor aponeurosis

Ectropian

• Outward rotation of the eyelid margin
• Occurs in 4% of the population over 50 years (sometimes bilateral)
• Signs: conjunctival hyperemia, corneal exposure, tearing, keratitis, globe apposition, keratinization of palpebral conjunctiva, visual loss, mucous discharge
• Management: surgery to remove part of lower eyelid, strengthen canthal tendons or inferior lid retractors, use ocular lubricants, bandage contact lenses to prevent eyelash rubbing against cornea, taping lower lid to the cheek

Pre-septal Cellulitis

• Common infection of eyelid and periorbital soft tissues, mainly affecting children (80% < 10 years old, most under 5)
• Symptoms: eyelid erythema, edema, possible fever, tiredness, irritability
• Separated from the orbital structures by the septum (preventing infection spreading into orbit) which often originates from URTI or paranasal sinus infections.
• Causes: Staphylococci, streptococci, anaerobes
• Symptoms: acute pain, swollen eyelid, redness, blurred vision, conjunctivitis, tearing
• Differential diagnoses: eyelid swelling (insect bites, allergic conjunctivitis, trauma, contact dermatitis, hordeolum)
• Management: confirm diagnosis, treatment of predisposing conditions, aggressive systemic antibiotics (IV in severe cases or younger children), potential need of CT scan of orbit and sinuses if antibiotics don't improve symptoms.

Bacterial Orbital Cellulitis

• Infection of tissues posterior to the septum
• Mostly spread from surrounding sinuses (often ethmoid) and adjacent structures like the nasolacrimal duct, trauma, surgery.
• Causative organisms: Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, Beta-hemolytic streptococci
• Symptoms: pain on eye movements, conjunctival chemosis, proptosis, ophthalmoplegia, reduced visual acuity, abnormal RAPD, progressing rapidly and systemically unwell children with fever and malaise.
• Treatment: confirm diagnosis, IV antibiotics for severe cases/young children

Tumors (basal and squamous cell carcinoma)

• Basal cell carcinoma: most common skin cancer, slow growing, destructive, locally invasive, non-healing ulcer (pearly-white borders), lower lid more affected than upper.
• Squamous cell carcinoma: rarer, aggressive, second most common eyelid malignancy, fair-skinned individuals, history of chronic sun exposure, possible association with other pre-cancerous lesions.
• Signs may include change in lid contour, redirection/loss of eyelashes, loss of surrounding skin texture, secondary infection/inflammation, threat of sight loss.

Benign Eyelid Lesions (cysts of Moll, Zeiss, Molluscum contagiosum)

• Cysts of Moll, Zeiss: sebaceous glands associated with lash follicles, cysts can develop when the follicles are blocked, leading to accumulation of sebaceous material. Cysts are removed for cosmetic reasons.
• Molluscum contagiosum: benign skin lesion, contagious, spreads with direct contact, presents as dome-shaped waxy nodules (2-3mm), releases toxic viral products, which may lead to follicular conjunctivitis.

Thyroid Eye Disease

• Most common in women (40-60s), systemic symptoms (tremor, weight loss), ocular symptoms (proptosis, lid retraction, lid lag, irritation, corneal dryness, lid edema, conjunctival chemosis, optic nerve compression with reduction in vision, colour vision, and visual field loss).