Eyelid Infections: Bacterial Infections PDF

Bacterial Infections Blepharitis: inflammation of the eyelid ○ Frequently is a combination of seborrheic and staphylococcus ○ Most common squamous type: No purulent Marginal hyperemia Marginal te...

Bacterial Infections Blepharitis: inflammation of the eyelid ○ Frequently is a combination of seborrheic and staphylococcus ○ Most common squamous type: No purulent Marginal hyperemia Marginal telangiectasia ○ Squamous types have an etiological component of hypersensibility, more common in patients w/ atopic dermatitis ○ May be caused by non-infectious factors as: Pollutants, makeup, soaps, preservatives Ask patient if they are using something new as these can be irritants and cause allergic dermatitis ○ Seborrheic dermatitis is associated with generalized areas (scalps, nasolabial folds, skin of the ears, eyebrows) ○ Bacterial (Staphylococcal): most common The most common bacteria around the eyes Gram + Normal lid margin flora S. Aureus and S. epidermidis are the most common strains associated to eye conditions  S. Aureus alpha-toxin causes irritation and is dermo necrotic Leading cause of marginal infiltrative keratitis Can cause corneal ulcers and will be located in border of cornea ○ Seborrheic: overproducing fat from the meibomian glands ○ Mixed: could be both Anterior with crusting and posterior lid margin redness or posterior to the gray line Commonly seen in pt with MGD Can lead to chronic conjunctivitis, madarosis, and tylosis Tx: hygiene or antibiotics ○ Signs - staphylococcal blepharitis Hard scales and crusting Mild papillary conjunctivitis Chronic conjunctival hyperemia Associated tear film instability and dry eye syndrome  ○ Symptoms of blepharitis Itching, red eye, burning, tearing, mild pain, foreign body sensation, filmy vision ○ Signs - seborrheic blepharitis Hyperemic and greasy anterior lid margins with soft scales and adherence of lashes ○ Chronic anterior blepharitis Surround the base of the eyelashes Staphylococcal or seborrhoeic Crusting or scales along eyelashes; be careful not to confuse with dermodex ‘Scurf’ (scale fragments) Collarets (scales that encircle the vase of the lash- pathognomonic for Dermodex) Madarosis can happen when chronic Lid margin redness Conjunctival injection  Complications: Pannus (opacity of the cornea) Phylctenules Corneal infiltrates Ulceration Treatment Daily application of hot compresses (10-15 min) to the eyelids followed by massage Lid scrub pads BID or TID, then QD (Ocusoft, Systane Lid Scrubs) Cotton-tipped applicator soaked in baby shampoo with water (more affordable than lid scrubs) Tea-tree oil shampoo - Dermodex Topical antibiotic ointment (Bacitracin or Erythromycin) QHS for 2-4 weeks AzaSite (Azithromycin) ophth. drops BID x 2 days then QD x 12 days (14) Inflammation: ○ Tobradex (Tobramycin + Dexamethasone) ointment qhs ○ Fluorometholone 0.1% (FML) or Loteprednol QID for 1 week (papillary conjunctivitis) Removing crusts lead to ulceration or bleeding Debridement in office (Blephadex) to reduce bacterial concentration ○ Chronic posterior blepharitis Meibomianitis, Meibomian Gland Dysfunction (MGD) Signs Excessive meibomian gland secretion Recurrent capping of meibomian gland orifices with oil globules Hyperemia Telangiectasis of the posterior lid margin (never acute, lasts > 3 weeks) Pressure on the lid margin results in expression of meibomian fluid that may be turbid or toothpaste-like Tear film is oily and foamy, and may accumulate on the lid margins Bacterial lipases break down lipids to soaps (foamy secretion)  Capping of meibomian gland orifices by oil globules Expressed toothpaste-like material Froth on the eyelid margin Treatment Hot compresses with fingertip massage 5-10 min QID Lid scrubs BID or TID, then QD Fish oil and Omega-3 fatty acids: EPA, DHA 2000 mg or flaxseed Short course (1-2 weeks) of topical steroid (Lotemax) or antibiotic-steroid (Tobradex) drops up to QID or ointment BID AzaSite (Azithromycin) ophth. drops BID x 2 days then QD x 12 days (14) Oral tx in moderate to severe or resistant  ○ Oral doxycycline 100 mg po bid x 4 wks, then 50-100 mg QD for 3-6 months (do NOT give doxy. to pregnant women) ○ Oral erythromycin 250 mg po bid then qd in pregnancy and breastfeeding ○ Azithromycin 500 mg x 3 days or Z pack (suppress inflammation) - can be given to pregnant women but erythromycin is better Consider topical cyclosporine 0.05% (Restasis) In-office heat or expression treatments also (LipiFlowm or intense pulsed light [IPL] or intraductal meibomian gland probing Treat associated pathology such as rosacea and dry eye ○ Ulcerative Blepharitis AKA Acute Marginal Blepharitis Acute inflammation Short duration Related to hordeolum (infection in sebaceous glands- acute) and chalazion (chronic) may occur Signs Eyelid margin infection at the base of eyelashes follicles and MG Eyelid margin edematous with crusted dried serous fluid in eyelashes Discharge, painful Could be prodromal of systemic illness (throat, ear)- URTIs, severe sinusitis Complicates with preseptal cellulitis (if blepharitis left untreated) ○ Angular blepharitis Caused by Moraxella lacunata or S. Aureus Symptoms: Canthal irritation - burning Tearing Crusting Skin hyperemia Signs: Red, scaly, macerated and fissured skin in the canthi Unilateral or bilateral  Skin chafing secondary to tear overflow (especially lateral canthus) Treatment: Erythromycin or Bacitracin ophth. ointment ○ Blepharoconjunctivitis Can have both symptoms, Hyperemia w/secretion- whitish/yellowish Viral- clear secretion Allergic- no secretion, just itchiness Hordeolum ○ External Hordeolum Stye, secondary to staph. infection (typically external, on margin) Acute Staphylococcal abscess of a lash follicle Gland of Zeis or Moll Common children and young adults Recurrent (associated with Staph Blepharitis) Poor diet, fatigue, stress Associations- rosacea, seborrheic dermatitis Signs: Tender swelling in the lid margin pointing anteriorly through the skin (lash in the apex) Painful, hot Multiple - can form an abscess Treatment: Self-limited (5-7d) Hot compresses 5-20 min bid-qid Epilation of the associated lash Antibiotics ○ Bacitracin ointment or Erythromycin 0.5% ointment qid in acute phase, then bid x 1 week Steroid in case of inflammation  ○ Internal Hordeolum Obstruction and infection of a meibomian gland Signs: swelling, erythema, tender, hot around lid, lesion visible on the tarsal conjunctiva More probability to complicate in preseptal cellulitis Treatment Onset and course of treatment longer than external hordeolum Topical antibiotics ineffective Mild cases ○ Hot compresses q 15-20 min or qid Moderate to severe ○ Oral antibiotics Doxycycline 100mg bid x7-10d Antibacterial and ant-inflammatory agent Dicloxacillin 250mg PO q 6hrs x 7-10 d Mild PCN allergy Cephalexin (Keflex®) 500 mg PO bid x 7-10 d Cefuroxime (Ceftin®) 500mg PO bid x 7-10 d Severe allergy PCN Azithromycin (Zithromax®) pack tab 500mg first day, then 250mg qd x 4 days Levofloxacin (Levaquin®) 500mg qd x 7-10d TMT/SMX (Bactrim®) bid 7-10d Recurrence (>3x in one year is considered recurrent) Tetracycline 250 mg bid hs qd for several months Doxycycline 50 mg qd x 6 months ○ Consider lid culture in recurrence ○ Suspect malignancy Injection of steroid  ○ Triamcinolone 0.2 to 1.0 ml (40 mg/ml) mixed 1:1 with 2% lidocaine w epinephrine ○ Preseptal Cellulitis Is an infection of the subcutaneous tissues anterior to the orbital septum Staphylococcus aureus and Streptococcus pyogenes Spread from focal ocular or periocular infection such as an acute hordeolum or skin trauma Signs: Unilateral eyelid erythema, edema, tender and warm Might not be able to open the eye No proptosis, no EOMs restriction Symptoms: Mild fever, redness, and lid tenderness Child irritability Does not have decreased vision, no pain w/ eye movements Versus orbital cellulitis does have decreased vision, pain w/ eye movements, diplopia CT scan - opacification anterior to the orbital septum Rule out orbital cellulitis Presents with decreased VA, diplopia (EOMs restriction), pain on movement, proptosis, RAPD Treatment Warm compresses tid If conjunctivitis is present: Polymyxin B/Bacitracin ointment qid  Amoxiclav®(amoxicillin/clavulanic acid) 250-500mg/125mg bid or tid or 875mg/125mg bid in severe x 10 d ○ Children 20-40mg/kg/d tid PO Ceclor® (cefaclor) 250-500 mg tid or 800mg bid x 10d ○ Children 20-40mg/kg/d in 3 doses Allergic PCN ○ Bactrim® (TMP/SMX) 160mg/800mg bid x 10d Children 8mg/kg/d TMP and 40mg/kg/d SMX in 2 doses ○ Erythromycin 250-500 mg qid x 10d Children 30-50mg/kg/d in 3 doses ○ Clindamycin 300 mg tid or qid x 7d ○ Azithromycin 500mg qd x 5 d If not responding to oral treatment, IV antibiotics should be considered Impetigo ○ Superficial skin infection ○ Staphylococcus aureus or Streptococcus pyogenes ○ Children ○ Eyelids is usually associated with infection of the face ○ Unhealthy living conditions ○ Signs Itching blisters Develop golden-yellow (honey) crusts on rupturing May have- fever, malaise, local lymphadenopathy Starts in one spot, touch or scratch spread to other areas ○ Treatment Avoid touching, sharing clothes Wound cleansing Topical Mupirocin, Bactobran ointment bid or tid x 7 d Beta-lactamase resistant Amoxiclav (amoxicillin/clavulanic acid) 875 mg/125 mg bid x 7 days Cephalexin 500 mg TID PO Clindamycin 300 mg tid PO ○ ○  Erysipelas ○ St. Anthony’s fire (“Holy Fire”) ○ Commonly associated with uncontrolled diabetes, obesity, alcohol abuse ○ Uncommon acute, severe, subcutaneous infection ○ Could present with lymph nodes infection ○ S. pyogenes or S. aureus ○ Ask for resent trauma or pharyngitis ○ Indurated, tender and erythematous subcutaneous plaque ○ Well-defined border distinguishes erysipelas from other cellulitis ○ Symptoms- Malaise, chills, fever (usually 48 hrs before skin involvement) Pruritus (itching), burning, tenderness and swelling ○ Rapid progression but not life-threatening ○ Treatment Tx for aches and fever (acetaminophen) Hydration and cold compresses Penicillin V 500 mg qid x 10 d first line of tx Erythromycin 500 mg qid x 10 d or Azithromycin 500 mg qd x 5 d in allergy to PCN ○ Necrotizing Fasciitis ○ Very severe infection ○ Involves subcutaneous tissue and skin ○ Progress rapidly to necrosis ○ S. pyogenes* or S. aureus ○ Signs: Periorbital redness and edema followed by formation of large bullae and black discoloration (necrosis) Due to thrombosis Complications Ophthalmic artery occlusion Lagophthalmos and disfigurement ○ IV antibiotics Penicillin G ○ Surgical debridement ○ Death may result ○ Acute Viral Inflammations Herpes Simplex ○ Primary infection or reactivation of herpes simplex virus (trigeminal ganglion) ○ HSV-1 (oral), rarely HSV-2 (genital) ○ Symptoms Prodromal facial and lid tingling (24 hrs) Pain, itching, redness Followed by: Eyelid and perioular lid vesicles with erythematous base (over 48 hrs) Lesions are all very similar Break and ulcerate Small crops of seropurulent vesicles Follow a single dermatome HZO typically unilateral Associated: Papillary conjunctivitis Discharge Lid swelling Punctate or dendritic corneal ulcers can develop (severe or eczema herpeticum)  ○ ○ Treatment Self-limited 10-14 d vesicles resolve Cold compresses bid or qid Oral systemic tx in severe cases (Immunocompromised, Keratitis disease or recurrences) Zovirax (Acyclovir) 400 mg PO 5x a day Famvir (Famciclovir) 500 mg PO * preferred Valtrex (Valaciclovir) 1 g PO tid x 7-10 d (lower doses but more $) Topical pt with blepharoconjunctivitis or corneal involvement Zirgan (Ganciclovir) gel 0.15% 5x a day Viropticv (Trifluridine) 1% ophth. sol. 9x a day Vira-A (Vidarabine) 3% gel 5x a day for 1-2 weeks Herpes Zoster ○ Reactivation of latent VZV in CN V (has to have hx to be dx) Chickenpox in children Shingles (“culebrilla”) adults ○ HZO usually involves upper eyelid, typically unilateral, follows dermatome one one side following trigeminal zones ○ Increase incidence and severity in >60 y/o ○ Signs Prodome Acute painful, unilateral, dermatomal maculopapular skin eruption (develop in 1 w) Followed by vesicular ulceration and crusting Pain becomes severe (trigeminal area) Resolve in 2-6 w Leaves permanent scarring ○ ○ Erythema and edema over the affected CN V1 dermatome ○ Hutchinson’s Sign- involvement of the tip or side of nose (nasociliary branch- ophth. nerve involvement) ○ Ocular Conjunctivitis 65% Keratitis 12% Complications 50% Untreated - lid scarring results in entropion, ectropion, trichiasis, madarosis, punctual stenosis, lid necrosis, lagophthalmos Common PHN - can last 3 months after onset of rash Chronic Recurrent 51% in 5 years ○ Cool saline or Domeboro (aluminum sulfate-calcium) compresses bid or tid ○ Topical Antibiotic - erythromycin or bacitracin ointment bid or tid in skin Systemic (start less than 72 hs onset of rash) Zovirax® (Acyclovir) 800mg PO 5 times/day 7- 10 d or Famivir® (famciclovir) 500mg qid PO 7-10d Valtrex® (Valacyclovir) 1g PO tid x 7-10d  Immunocompromised ○ Acyclovir 10-12 mg/kg/d IV q8hrs x 10-14 d ○ Rule out ocular involvement ○ Postherpetic neuralgia is the most common cause of shingles Tricyclic antidepressant (amitriptyline, doxepin) Gabapentin (Neurontin® 600mg PO 2-6 times/day) - common to use Pregabalin (Lyrica ® 300-600 mg PO qd) Prednisolone 60mg x 3d, then 40mg x3d, then 20mg x 4 d and d/c (minimize PHN) No immunocompromise, DM, TB ○ Vaccination > 50 y/o Zostavax reduces 51% incidence herpes zoster and 67% PHN Shingrex (more effective) - more than 90% of effectivity * 2 doses 2-6 mo. apart ○ ○ ○  Molluscum Contagiosum ○ DNA poxvirus infection ○ Children 2-4 y/o ○ Immunocompromise (HIV+) ○ Spread by direct contact, autoinoculation ○ ○ Asymptomatic ○ Shiny dome-shape waxy (pearlated) papules with central umbilication ○ Multiple, occasionally confluent ○ Adults STD associated ○ Lid or lid-margin ○ Papules anywhere on the body (abdomen, pubis, genitals) ○ Associated Chronic follicular conjunctivitis * (suspect of molluscum if not responding to topical antibiotics) Superficial pannus SPK ○ Self-limited 6-18 months (but could take years) ○ Immunocompromise (AIDS) – disseminated disease ○ Treatment Excisional Biopsy with Curettage* Cryotherapy Cauterization ○ Other topical treatments Potassium hydroxide liquid BID until lesions get inflamed and stop (no more 14 days) Tretinoin liquid or cream bid (no pregnancy) Immunocompromised Immunomodulators: Imiquimod (Zyclara) 3.75% topical cream  ○ ○ - Lid margin nodule Common Infestations Pediculosis ○ Infestation with lice ○ ○ Phthirus pubis ○ Sexually transmitted or close contact ○ Symptoms: itching, burning, irritation ○ Signs Small pearly white (translucent) nits (eggs) attached to lashes or adult lice Dark coloration of lids due to fecal material Preauricular lymphadenopathy  Conjunctival follicles Conjunctival injection ○ Mechanical removal of lice and nits with fine forceps Antibiotic ointment or petroleum jelly will help ○ Epilate lashes with eggs or cryotherapy ○ Physostigmine 0.25% ointment x 1 (repeat in 1 week) [lower IOP, miosis] ○ Erythromycin ophth. ointment tid for 14 days to suffocate lice ○ Lindane 1% shampoo for body lesions no for eye ○ Discard or thoroughly wash in hot cycle all bedding, lines, and clothing ○ Treat sexual partner or family members Dermodex folliculorum ○ Parasitic hair follicles infection by Dermodex folliculorum or Dermodex brevis ○ ○ Asymptomatic - low infestation ○ Signs Thin semitransparent crusting at the lashes base in the hair follicles Irritation, redness, itching Collarets ○ Parasite consumes epithelial cells- causes hyperplasia and keratinization- leads to cuffing (keratin and lipid) ○ Accumulation of waste material in follicles and sebaceous glands ○ Treatment Tea tree oil lid scrubs Blephadex - most effective BID base of lashes Omega 3 and 6 fatty acids Resistant oral tx Ivermectin 200 mcg/kg PO single dose, then repeat in 7 days ○  Tick infestation of the eyelid ○ Should be removed, to prevent risk Lyme disease Rocky mountain fever African tick bite fever Tularemia ○ Detached complete the head and mouthparts ○ Doxycycline prophylactic ○ Monitor symptoms for the following week (4-10 d) ○ African tick on lid margin ○ 2 weeks after removal Chronic Inflammations Chalazion ○ Sterile lipogranulomatous ○ Obstruction of a meibomian gland ○ May follow an internal hordeolum ○ Could be associated to chronic blepharitis ○ Signs Well-defined, immobile, firm, non-tender nodule (2-8 mm) ○ Chalazia that do not resolve with conservative treatment may require intralesional steroid injection or surgical excision ○ ○ Treatment Warm compresses with gentle massage for 10-20 min qid Topical antibiotic ointment (erythromycin or bacitracin bid to tid) if lesion is draining Topical antibiotic- steroid ointment (Tobradex bid) with inflammation Incision and curettage Intralesional steroid injection (triamcinolone 40 mg/mL inject 0.5 mL with a 30-gauge needle) - not in dark skin Recurrent lesion - biopsy to rule out malignancy (sebaceous carcinoma) Treat underlying meibomitis and rosacea Multiple and recurrent Doxycycline 50 mg PO or minocycline 25 mg po bid Tetracycline 250 mg (not in pregnancy or children) Erythromycin 250 mg PO bid may be used  Meibomianitis ○ Inflammation of the MG ○ Related to poor blinking, poor diet, dermodex, rosacea, CL, or aging ○ Most dry eye disease pt have MGD ○ Symptoms: FB sensation, tearing, burning, dry eye ○ Signs: hyperemic lid margins, capping, creamy secretion upon expression, SPK ○ Treatment: as MGD ○ Acne Rosacea ○ Chronic inflammatory disorder ○ Face flush and acne (nose cheeks, chin, forehead) ○ Ocular signs or symptoms 20% before cutaneous manifestation ○ 5% corneal disease ○ Symptoms: burning, FB sensation, watery eyes ○ Signs: erythema and edema of eyelids, clogged MG, common chalazion or hordeolum ○ Rosacea triggers factors so you might try to avoid: Being outside in the hear, sun, wind, or cold Doing very active sports such as running Drinking alcohol Eating spicy foods Drinking hot coffee or tea Feeling stressed or upset  ○ Treatment Antibiotic with steroid Tobradex (tobramycin/dexamethasone) qid x 7-10 d Consider topical azithromycin (Azasite bid for 2 days; then qd for 2-4 wks) Artificial tears Eyelid scrubs or baby shampoo Oral antibiotics (tetracyclines) Doxycycline 100 mg bid x 3 weeks Minocycline 50 mg PO bid, then qd 3 months Metrogel (Metronidazole) 0.75% bid 2-4 w affected area (no eye) ○ ○ Hypersensitivity Reactions Acute allergic blepharoedema ○ Caused by exposure to pollen or by insect bites ○ Type 1 hypersensitivity (IgE) ○ Sudden onset of bilateral boggy periocular edema ○ Chemosis commonly ○ Treatment: Oral antihistamines Benadryl diphenhydramine 25-50 mg tid or qid Loratadine 10 mg daily ○  ○ Contact dermatitis ○ Skin inflammation in response to exposure Medication topical Soaps, fragrances Cosmetics Poison ivy ○ Type IV hypersensitivity ○ Symptoms: itching, FB sensation, swelling, redness ○ Signs Lid skin scaling or crusting rash Angular fissuring Edema Tightness Could have chemosis, redness, or papillary conjunctivitis ○ Treatment Avoid allergen exposure Cold compresses Topical steroids x 2 weeks Mild cream steroid hydrocortisone 1% or betamethasone 0.1% cream Oral antihistamines Benadryl diphenhydramine 25-50 mg tid or qid Loratadine 10 mg daily Topical antibiotic in crusted lesions (bacitracin or erythromycin ointment) ○ Atopic dermatitis ○ AKA eczema ○ Common idiopathic condition ○ Pt with asthma or hay fever ○ Signs Dermatitis eyelids Thickening, crusting, and fissuring  Darker skin (inflammation) Associated staph blepharitis, venal or atopic keratoconjunctivitis ○ Treatment Emollients Topical steroid as hydrocortisone 1% ○