08- Ophthalmic Disorders.pdf

Ophthalmic Disorders DR. I B R A H I M A L- A DHA M TA KE N F ROM HA N DBOOK OF N ON P R ESCRIPTI ON DR U G S > CHA PT E R 2 7 1  Ophthalmic Disorders: Introduction The non-prescription o...

Ophthalmic Disorders DR. I B R A H I M A L- A DHA M TA KE N F ROM HA N DBOOK OF N ON P R ESCRIPTI ON DR U G S > CHA PT E R 2 7 1  Ophthalmic Disorders: Introduction The non-prescription ophthalmic market consists of products that treat a wide range of disorders. Many common conditions that cause ocular discomfort are minor and self limiting. In some instances, however, relatively minor symptoms may be associated with severe, potentially vision threatening conditions. 2  Ophthalmic Disorders: Introduction Self treatable ophthalmic disorders occur primarily on the eyelids; however, a few disorders of the eye surface may be responsive to self treatment. The latter include dry eyes, allergic conjunctivitis, diagnosed corneal edema, presence of loose foreign debris, minor ocular irritation, and the cleaning or lubricating of artificial eyes. Careful assessment is important, especially with ongoing symptoms, to rule out more complicated manifestations that may require referral to an eye care specialist. 3  Role of Eye Anatomy in Ocular Drug Pharmacokinetics The external location and exposure of the eye make it susceptible to environmental and microbiologic contamination. The eye has many natural defense mechanisms to protect it against contamination, however, and the eyelid is one of its major protective elements. The eyelids are a multilayer tissue covered externally by the skin and internally by a thin, mucocutaneous epithelial layer called the palpebral conjunctiva. The tear layer keeps the ocular surface lubricated, provides a mechanism for removing debris that touches the ocular surface, and has potent antimicrobial action provided by specific enzymes and a number of immunoglobulins (including the most prevalent, immunoglobulin A). 4  Role of Eye Anatomy in Ocular Drug Pharmacokinetics The tear layer is a complex, multilayer film. The outer lipid layer maintains the eyes optical properties and reduces evaporation. The middle aqueous layer is largely responsible for the wetting properties of the tear film. The inner mucinous layer allows the outer lipid and middle aqueous layers to maintain constant adhesion across the cornea and conjunctiva. Abnormalities within any one of the tear layers can result in ocular discomfort. 5 Reflex tearing occurs immediately on instillation of a drug into the eye, diluting the drug’s concentration. Drug penetration into the eye is reduced because of increased lacrimal drainage and tearing that falls down the cheek. Studies have shown that as much as 90% of an instilled dose of a drug administered to the eye may be lost. 6 Anatomy of the eyelid and eye surface. 7  Dry Eye Disease Pathophysiology and Clinical Presentation of Dry Eye: Dry eye disease is among the most common disorders affecting the anterior eye. Most often associated with the aging process (especially with postmenopausal women), Dry eye also can be caused by lid defects, corneal defects, loss of lid tissue turgor, Sjögren’s syndrome, Bell’s palsy, thyroid eye disease, various collagen diseases (e.g., rheumatoid arthritis), and systemic medications. Refractive surgery patients may complain of transient dry eyes for weeks to months after the procedure 8  Dry Eye Disease Failure to properly diagnose and treat dry eye diseases can result in severe damage to eye tissue, particularly to the corneal surface. Recent evidence demonstrates that dry eye disease can be linked to a T-cell mediated Inflammatory process, which can respond to immunomodulatory agents (e.g., cyclosporine). 9  Treatment of Dry Eye Disease The goal in treating dry eye disease is to alleviate and control the dryness of the ocular surface, thereby relieving the symptoms of irritation and preventing possible tissue and corneal damage. Although dry eye disease also has been referred to as “dysfunctional tear syndrome,” “kerato-conjunctivitis sicca,” and “dry eye disease,” a recent published report of the International Dry Eye Workshop (DEWS) accepted “dry eye disease” as the most appropriate term. 10  General Treatment Approach The primary self treatment for dry eye disease is the use of ocular lubricants. However, treatment of mild and moderate dry eye disease also includes other pharmacologic and non-pharmacologic recommendations, Which including education, environmental modifications, eyelid therapy, elimination of offending topical or systemic medications, and use of systemic omega-3 -fatty acid supplements (e.g., flax seed oil). 11  General Treatment Approach Artificial tears help alleviate dryness of the ocular surface. Artificial tear products vary by viscosity according to the ingredients used in their preparation. Increasing the viscosity of a product results in a more prolonged ocular contact time and greater resistance to tear dilution. Mild cases of dry eye disease may be treated with less viscous products, whereas more severe cases may require more viscous products. 12  General Treatment Approach Bland (i.e., nonmedicated) ophthalmic ointment (e.g., petrolatum) is another type of ocular lubricant. Because ointment preparations tend to cause blurred vision, they are typically reserved for use only at bedtime or for severe cases of dry eye. As with ointments, the more viscous the tear drops are, the greater their blurring effect becomes. Vitamin A preparations are also available for treating dry eye disease. 13  Nonpharmacologic Therapy The primary nondrug measure is avoiding environments that increase evaporation of the tear film. If possible, patients should avoid dry or dusty places. Using humidifiers or repositioning workstations away from heating and air conditioning vents may help alleviate dry eyes. In addition, avoiding prolonged use of computer screens and wearing eye protection (e.g., sunglasses or goggles) in windy, outdoor environments may further help alleviate dry eye problems. 14  Pharmacologic Therapy Artificial Tear Solutions Lubricants that are formulated as artificial tear solutions consist of preservatives, inorganic electrolytes to achieve tonicity and maintain pH, and water soluble polymeric systems. The lubricating agents in artificial tear products are similar, but buffering agents, preservatives, pH, and other formulation components may vary. The newer artificial tear substitutes have important properties, including their ability to stabilize the tear film, protect the corneal and conjunctival cells, reduce tear evaporation with the combination of lipids, and enhance wound healing and lubrication of the ocular surface. 15 Components of Nonprescription Ophthalmic Lubricants Artificial Tear Solutions Hydroxypropyl methylcellulose 0.3%; dextran 70, 0.1% Sorbic acid 0.25%; EDTA 0.1%; NaCl; hypromellose; glycerin PVA 1.4%; sodium phosphate; NaCl; BAK 0.01%; EDTA Glycerin 0.25%; EDTA; NaCl; BAK Hydroxypropyl methylcellulose; boric acid; phosphonic acid; NaCl; sodium perborate PVA 1%; PEG 400; BAK 0.01% Hydroxypropyl methylcellulose 2906, 0.3%; dextran 70, 0.1%; EDTA; KCl; NaCl; BAK 0.01% PVA 1.4%; povidone 0.6% CMC sodium 0.5% PEG-400, 0.4%; propylene glycol 0.3%; boric acid; calcium chloride; hydroxypropyl guar; magnesium chloride; polyquaternium preservative; KCl; NaCl; zinc chloride; water 16 Components of Nonprescription Ophthalmic Lubricants Non-medicated Gels Hydroxypropyl methylcellulose 0.3%; sodium perborate 0.028%; carbopol 980; phosphoric acid; sorbitol CMC 1%; KCl; sodium bicarbonate; NaCl; sodium phosphate Key: BAK = Benzalkonium chloride; CMC = carboxymethylcellulose; EDTA = ethylenediamine tetraacetic acid; KCl = potassium chloride; NaCl = sodium chloride; PEG = polyethylene glycol; PVA = polyvinyl alcohol. 17 PVA is compatible with many commonly used drugs and preservatives, certain compounds (e.g., sodium bicarbonate, sodium borate, the sulfates of sodium, potassium, and zinc) can thicken or gel solutions containing PVA. For example, sodium borate is found in some extraocular irrigating solutions or irrigants and may react with contact lens wetting solutions that contain PVA. Therefore, health care providers must be cautious when recommending solutions containing PVA. 18  Non-medicated Ophthalmic Ointments The primary ingredients in commercial nonprescription ophthalmic ointments are: ❖white petrolatum 60% (which contains a lubricant and an ointment base), ❖mineral oil 40% (which helps the ointment melt at body temperature), ❖lanolin (which facilitates incorporation of water soluble medications and also prevents evaporation). 19  Non-medicated Ophthalmic Ointments The principal advantage of nonmedicated (bland) ointments is their enhanced retention time in the eye, which appears to enhance the integrity of the tear film. Therefore, mucinand aqueous deficient eyes can benefit from them application of lubricating ointments. Ointment formulations are usually administered twice daily. However, depending on the patient’s clinical needs and therapeutic response, ointments may be administered as often as every few hours or only occasionally, as needed. Many patients prefer to instill the ointment at bedtime to keep the eyes moist during sleep and improve morning symptoms of dry eye. 20  Non-medicated Ophthalmic Ointments Because of the viscosity of the melted ointment base in the tear film, many patients complain of blurred vision when using ointments. This problem can usually be managed by decreasing the amount of ointment instilled or by administering the ointment at bedtime. Providers should routinely counsel patients about the blurred vision associated with eye ointments. 21 Administration Guidelines for Eyedrops 22  Formulation Considerations for Ocular Lubricants and Other Ophthalmic Products Ocular lubricants and other non-prescription ophthalmic drugs are formulated to reduce the stinging, burning, and other side effects commonly associated with some ophthalmic drugs. These products are comfortable to use because their pH is carefully controlled, and because they use buffers, tonicity adjusters, and preservative systems; therefore, they encourage patients to adhere to self treatment. Drug vehicle and preservative systems are among the most important inactive ingredients of these products. 23 Allergic Conjunctivitis 24  Allergic Conjunctivitis Pathophysiology and Clinical Presentation of Allergic Conjunctivitis: The list of antigens that can cause ocular allergy is virtually endless, but the most common allergens include pollen, animal dander, and topical eye preparations. Patients with ocular allergy will often report seasonal allergic rhinitis, as well. Allergic conjunctivitis is characterized by a red eye with watery discharge The hallmark symptom of ocular allergy is itching. Vision is usually not impaired but may be blurred because of excessive tearing. Contact lenses should not be used until the condition resolves. 25 26 Treatment of Allergic Conjunctivitis Treatment Goals: The goals in treating allergic conjunctivitis are to: 1. Remove or avoid the allergen, 2. Limit or reduce the severity of the allergic reaction, 3. Provide symptomatic relief, and 4. Protect the ocular surface. 27  General Treatment Approach Questioning the patient about exposure to allergens may help identify the offending substance. Removal or avoidance of the responsible allergen is the best treatment, but non-prescription ocular lubricants, ocular decongestants, ocular decongestant/antihistamine preparations, ocular antihistamines/mast cell stabilizers, oral antihistamines, and cold compresses will help relieve symptoms. 28  Nonpharmacologic Therapy In addition to removing and/or avoiding exposure to the offending allergen, applying cold compresses to the eyes 3-4 times per day will help reduce redness and itching. Other important measures for avoiding the allergic response include checking the pollen count, keeping doors and windows closed, running air conditioning, using air filters, and so on. 29  Pharmacologic Therapy The firstline treatment of allergic conjunctivitis is to instill artificial tears as needed. If symptoms persist, the patient should switch to an ophthalmic antihistamine/mast cell stabilizer product. Ketotifen fumarate 0.025% is very safe and can be used in individuals ages 3 years and older; it is dosed twice daily and is very effective in relieving the signs and symptoms of allergic conjunctivitis. An oral antihistamine can be added to the second treatment option, if needed. 30 Ophthalmic Decongestants / Alpha-Adrenergic Agonists Four decongestants are available in nonprescription strength for topical application to the eye: phenylephrine, naphazoline, tetrahydrozoline, and oxymetazoline. In nonprescription ophthalmic products, phenylephrine is available in a concentration of 0.12% or lower. Higher concentrations of phenylephrine (2.5% and 10%) are prescription products and are used for pupillary dilation. Phenylephrine acts primarily on alpha-adrenergic receptors of the ophthalmic vasculature to constrict conjunctival vessels, thereby reducing eye redness. Naphazoline, tetrahydrozoline, and oxymetazoline are chemically classified as imidazoles, these agents are available as solutions in a variety of concentrations. 31  Ophthalmic Decongestants / Alpha-Adrenergic Agonists Similar to phenylephrine, the imidazoles have greater alpha than beta receptor activity and, therefore, are clinically useful in constricting conjunctival blood vessels. These agents have only minimal effect on the underlying vessels of the episclera and sclera. Vasoconstrictors are effective in constricting conjunctival vessels and in reducing redness, vascular congestion, and eyelid edema, but they do not diminish the allergic response. 32 Ophthalmic Decongestants / Alpha-Adrenergic Agonists When used as directed, ocular decongestants generally do not induce ocular or systemic side effects. However, their availability to and use in children should be monitored carefully. Ingestion of these products can result in coronary emergencies and death. When used excessively or long term, ocular decongestants have the potential to produce rebound conjunctival hyperemia (i.e., rebound conjunctival congestion), allergic conjunctivitis, and allergic blepharitis. Thus, they should not be used for more than 72 hours. Rebound congestion appears to be less likely with topical ocular use of naphazoline or tetrahydrozoline than with oxymetazoline or phenylephrine. 33 Ophthalmic Decongestants / Alpha-Adrenergic Agonists Ocular decongestants should be used cautiously by patients with systemic hypertension, arteriosclerosis, other cardiovascular diseases, or diabetes. Adverse cardiovascular events are also possible when these agents are used in patients with hyperthyroidism. Because of these possible adverse reactions, patients should not use phenylephrine and other ocular decongestants as ocular irrigants. During pregnancy, women should use ocular decongestants sparingly, if at all. Storing solutions at high temperatures may cause ocular reactions and severe mydriatic responses to instillation. If offending ophthalmic signs or symptoms do not resolve within 72 hours, the patient should see an eye care provider. 34  Ophthalmic Antihistamines and Ophthalmologic Antihistamines/ Mast Cell Stabilizers Two non-prescription antihistamines are available for topical ophthalmic use: pheniramine maleate and antazoline phosphate. Although these antihistamines are effective alone, non-prescription products containing them also contain a decongestant. The two combinations are pheniramine/naphazoline and antazoline/naphazoline. Pheniramine and antazoline are in different antihistamine classes, but both act as specific histamine1-receptor antagonists. 35 Topical antihistamines are used for rapid relief of symptoms associated with Intermittent or atopic conjunctivitis. Using a decongestant with either topical antihistamine has been shown to be more effective than using either agent alone. Ketotifen fumarate is an ophthalmic antihistamine and mast cell stabilizer. It produces very potent H1receptor antagonist activity, thereby preventing acute histamine mediated allergy symptoms. The mast cell stabilization activity inhibits mast cell degranulation, preventing the release of inflammatory mediators, including histamine. Ketotifen also inhibits eosinophils, thereby inhibiting the release of latephase mediators. Ketotifen provides relief within minutes. Its effects may last up to 12 hours from a single dose, and it does not contain a vasoconstrictor; therefore, it is a very safe product with no concerns for vasoconstrictor overuse. 36 Burning, stinging, and discomfort on instillation are the most common side effects of ophthalmic antihistamines. Ophthalmic antihistamines have anticholinergic properties and may cause pupil dilation. This effect is seen most commonly in people with light colored irises or compromised corneas (e.g., contact lens wearers) 37  Product Selection Guidelines Ketotifen is the safest and most effective product for the treatment of allergic conjunctivitis. It is the greatest improvement in the nonprescription treatment of allergic eye disease in many years. The twice daily dosing and the safety of this product for children ages 3 years and older make it the primary therapy for patients with signs and symptoms of allergic conjunctivitis. Naphazoline 0.02%, however, is an excellent choice for nonprescription therapy of mild-moderate conjunctivitis of environmental, viral, or non-infectious origin. Because rebound congestion appears to be less likely after topical ocular use of naphazoline or tetrahydrozoline, these agents should generally be recommended over phenylephrine or oxymetazoline 38  Corneal Edema Corneal edema may occur from a variety of conditions, including over-wear of contact lenses, surgical damage to the cornea, and inherited corneal dystrophies. 39  Treatment of Corneal Edema The goal in treating corneal edema is to draw fluid from the cornea, thereby relieving the associated symptoms. Once the initial diagnosis is established, patients can use topical hyperosmotic formulations to treat corneal edema. Of the topical ophthalmic hyperosmotic agents available, only sodium chloride can be obtained without a prescription in both solution and ointment formulations. 40  Treatment of Corneal Edema Sodium chloride is available as a 2% or 5% solution and as a 5% ointment. First line treatment is instillation of a 2% solution 4 times per day. If symptoms persist, night time use of a 5% hyperosmotic ointment should be added to the regimen. If symptoms do not respond to the augmented treatment, the patient should switch to a 5% hyperosmotic solution and continue night time use of the ointment. If symptoms still persist, medical referral is necessary. 41  Loose Foreign Substances in the Eye Despite the protective effect of the eyelids, foreign substances often contact the ocular surface. The immediate response of the eye is watering (tearing). If the substance causes only minor irritation and does not abrade the eye surface, self treatment is appropriate 42  Treatment of Loose Foreign Substances in the Eye Treatment Goals: The goal in treating loose foreign substances in the eye is to remove the irritant by irrigating the eye. If a known foreign substance is a fragment of wood or metal, it should be treated promptly by an eye care provider because of the potential for penetrating injuries. 43  General Treatment Approach If reflex tearing does not remove the foreign substance, the eye may need to be flushed. Lint, dust, and similar materials can usually be removed by rinsing the eye with sterile saline or specific eyewash preparations (irrigants). If needed, eye ointment can be applied at bedtime. 44  Pharmacologic Therapy Ocular Irrigants:- An ocular irrigant is used to cleanse ocular tissues while maintaining their moisture; these solutions must be physiologically balanced with respect to pH and osmolality. Because the tissues that the irrigant contacts obtain nutrients elsewhere, the role of irrigants is primarily to clear away unwanted materials or debris from the ocular surface. To reduce risk of contamination, patients should use ocular irrigants only on a short term basis, and they should be sure that no other ocular pathology is being missed. All ophthalmic irrigating solutions are available without a prescription 45  Ocular Irrigants Ocular irrigants should not be used for open wounds in or near the eyes. Although irrigating solutions may be used to wash out the eyes after contact lens wear, they have no particular value as contact lens wetting, cleansing, or cushioning solutions. If the patient experiences continuous eye pain, changes in vision, or continued redness or irritation of the eye, or if the ocular condition persists or worsens, evaluation by an eye care provider should be strongly encouraged. Irrigants may be packaged with an eyecup; however, because contamination of the eyecup is possible, it should not be used to rinse the eye. 46  Minor Eye Irritation Non-allergic, minor eye irritation can be caused by a loose foreign substance in the eye; contact lens wear; or exposure of the eye to wind, sun (e.g., snow skiing without protective eye goggles), smog, chemical fumes, or chlorine. Redness of the eye is a common sign of minor irritation. In cases of snow blindness, other burns from UV light, or arc welder’s burns, common additional symptoms include pain and the feeling of “sand in the eyes’’ 47  Treatment of Minor Eye Irritation Minor irritation often responds well to artificial tear solutions or non-medicated ointments Zinc sulfate, a mild astringent, may be recommended for temporary relief of minor ocular irritation. The dosage is 1-2 drops up to 4 times daily. 48  Chemical Burn Chemical burns may occur from exposure to ◦ Alkali (e.g., oven cleaners, cement, or lye); ◦ Acids (e.g., battery acid or vinegar); ◦ Detergents; and various Solvents and Irritants (e.g., tear gas or mace). Burns may range from mild to severe, depending on the inciting agent and/or exposure time. Patients complain of pain, irritation, photophobia, and tearing. 49  Chemical Burn Less severe signs include superficial punctate keratitis (small pinpoint loss of epithelial cells in the cornea), perilimbal ischemia, chemosis, hyperemia, eyelid edema, hemorrhages, and first or Second degree burns of the lid and outer skin. More severe signs include corneal edema and opacification, anterior chamber inflammation, increased IOP, and retinal toxicity from scleral penetration. Alkali burns are more penetrating and potentially more damaging to eye tissues than acid burns. Alkali burns often are more resistant to irrigation and have greater tissue destruction when they penetrate into the deeper (stromal) layers of the cornea. 50  Emergent Treatment of Chemical Burn Emergent treatment includes immediate copious irrigation with sterile saline or even tap water (although it should be avoided in our country due to high contamination) Irrigation must be continued until an eye care provider can be seen; if irrigation is stopped prematurely, residual material that may still be under the lid or in the inferior culdesac may cause the pH of the tear film to revert to either acidic or alkaline. 51  Emergent Treatment of Chemical Burn Further treatment after irrigation may include the use of cycloplegic agents, topical antibiotics, and analgesics. In more severe cases, if significant inflammation of the anterior chamber or cornea is present, eye care specialists may use topical steroids. Anti-glaucoma medications are also used if the IOP is elevated. ( after consulting the Health care provider) Followup by the eye care provider is required to prevent conjunctival adhesions and corneal complications. Chemical burns are considered ophthalmic emergencies and should be referred to an eye care provider or emergency department immediately. 52  Contact Dermatitis Contact dermatitis of the eyelid can be a reaction to either an allergen or an irritant. Causes of contact dermatitis include a change in cosmetics or soap, exposure to eye medications, or contact with other foreign substances. The involvement of both eyelids suggests allergy, because both eyes are often exposed. Common symptoms include swelling, scaling, or redness of the eyelid, along with profuse itching. Sunburns of the eyelids and UV burns to the cornea (e.g., recent sun exposure from beach or ski outings without eye protection) should be ruled out. 53  Treatment of Contact Dermatitis Questioning the patient about the use of eye medications or new products (e.g., eyeliner or eye shadow) may help identify the offending substance quickly. Discontinuing use of the suspected product is the best treatment. If swelling of the eyelid is marked, non-prescription oral antihistamines (e.g. diphenhydramine) along with cold compresses applied 3-4 times per day will help reduce the inflammation and itching. 54  Viral Conjunctivitis PROF. IBRAHIM AL-ADHAM TAKEN FROM HANDBOOK OF NONPRESCRIPTION DRUGS  Etiology/Signs and Symptoms of Viral Conjunctivitis Viral conjunctivitis is the most common form of conjunctivitis. A recent cold, sore throat, or exposure to someone with "pinkeye" (viral conjunctivitis) is a common precursor of this condition. Individuals with viral conjunctivitis will usually have a pink eye with a copious amount of watery discharge. Symptoms include nondescript ocular discomfort and a mild-to-moderate sensation of a foreign object in the eye; vision may occasionally be blurred. Low-grade fever may be present, and swollen preauricular or submandibular lymph nodes may be found. If the etiology of the conjunctivitis is not clear, the patient should be referred to an optometrist or ophthalmologist.  Treatment of Viral Conjunctivitis Treatment Outcomes The goal in treating viral conjunctivitis is to relieve symptoms while the infection runs its course. General Treatment Approach Viral conjunctivitis is usually self-limiting, with symptoms resolving over 1 to 3 weeks. Treatment to relieve major symptoms should use artificial tear preparations and ocular decongestants. Because certain forms of viral conjunctivitis can be extremely contagious, non-pharmacologic hygienic measures are also important.  The Therapy Non-pharmacologic Therapy ◦ Patients with viral conjunctivitis should wash their hands after touching an infected eye and should properly dispose of tissues used to blot an infected eye. ◦ They should also avoid sharing towels or other objects that might come in contact with their infected eye. Pharmacologic Therapy As discussed previously "Treatment of Dry Eye“ & "Treatment of Allergic- ocular decongestants’’. Lice Infestation of the Eyelid  Etiology/Signs and Symptoms of Lice Infestation of the Eyelid Infestation of the eyelids with the organisms Phthirus pubis (crab louse) or Pediculus humanus capitis (head louse) may cause symptoms similar to blepharitis (i.e., red, scaly, thickened eyelids). These organisms are also responsible for sexually transmitted lice infestation. Children are rarely affected by the crab louse but are commonly affected by the head louse.  Treatment of Lice Infestation of the Eyelid A bland (non-medicated) ophthalmic ointment (e.g., petrolatum) used for 10 days is the recommended self- treatment. The ointment suffocates the louse and deprives its eggs of adequate oxygen to hatch. Pharmacists should carefully instruct patients about the need to take hygienic measures, such as washing clothing and bedding that may contain unhatched eggs. Blepharitis  Etiology/Signs and Symptoms of Blepharitis Blepharitis is an extremely common inflammatory condition of the eyelid margins. The most common causative factors are Staphylococcus epidermidis, Staphylococcus aureus, seborrheic dermatitis, or a combination of these factors. Red, scaly, thickened eyelids—often with loss of the eyelashes— are typical signs of blepharitis. Itching and burning are the most common accompanying complaints. All forms of blepharitis tend to be chronic, and individuals are often aware of their diagnosis. Treatment of Blepharitis Treatment Outcomes The goals in treating blepharitis are to 1. Control the disorder with good eyelid hygiene and 2. Provide symptomatic relief. Hordeolum/Chalazion  Etiology/Signs and Symptoms of Hordeolum/Chalazion An internal hordeolum is an inflammation of the meibomian gland, whereas an external hordeolum is an inflammation of the glands of Zeis and Moll. A palpable, tender nodule is always present. Swelling of the eyelid, almost to the point of closure, can occur with a severe internal hordeolum. The cause is invariably one of the staphylococcal species associated with blepharitis. A chalazion, which is a sterile granuloma, is very similar in appearance to an internal hordeolum. However, a chalazion is not tender to gentle touching, whereas a hordeolum is typically quite tender.  Treatment of Hordeolum/ChaIazion A hordeolum typically responds well to hot compresses applied three to four times daily for 5 to 10 minutes at each session. Clearing usually occurs within 1 week. An external hordeolum may be treated with a topical antibiotic, however an internal hordeolum does not respond well to such treatment and is best treated with a course of oral prescription antibiotics. Surgical drainage may be required in recalcitrant cases. Hot compresses applied the same as for treatment of hordeola are usually sufficient to drain a chalazion. If either disorder does not drain within 1 week or has been present chronically, medical referral is appropriate. Periodic use of lid scrubs may reduce the recurrences of chalazion and hordeolum.