5 Eyelid and anterior segment

Question 1

Blepharitis

Answer 1

Warm compresses followed by lid scrubs
Artificial tears for associated dry eye
Hypochlorous acid products
Consider antibiotic ointment bid or qhs
Maintenance therapy

Question 2

Meibomitis

Answer 2

Warm compresses followed by lid massage
Artificial tears for associated dry eye
Consider omega omega-3 supplementation
Consider low-dose oral doxycycline
In-office gland expression
Maintenance therapy

Question 3

Demodex

Answer 3

Warm compresses followed by lid scrubs
Tea tree oil (Terpinen-4-ol) containing eyelid scrubs or foam
In-office treatment of eyelashes
Alternative: hypochlorous acid products, oral ivermectin

Question 4

Ocular Rosacea

Answer 4

Same as blepharitis and
meibomitis plus:
Avoidance of exacerbating food and environmental triggers
Oral doxycycline 50 or 100mg qd or bid
* Alternative: oral erythromycin or azithromycin!!!!!

Consider omega omega-3, cyclosporine 0.05% drops bid, topical steroid
Intense pulsed light (IPL) therapy
Topical gel applied to the face (e.g. brimonidine 0.33% gel, metronidazole 0.75%)

Question 5

Hordeolum

Answer 5

Warm compresses 15 minutes qid with light massage
Consider topical or oral antibiotic
If the hordeolum worsens and spreads along the eyelid, treat as preseptal cellulitis.

Question 6

Chalazion

Answer 6

Warm compresses 15 minutes qid with light massage
Oral doxycycline

If it does not resolve in 3
3-4 weeks:
Incision and drainage
Intralesional steroid injection (i.e. triamcinolone)
>Can lead to permanent depigmentation of the skin at the injection site.

Question 7

preseptal cellulitis

Answer 7

Mild to moderate infections in adults:
*
Augmentin (amoxicillin/ clavulanate ) 875/125mg po q12h for 1 week
or Cephalexin 500mg q12h for 1 week
or Trimethoprim/Sulfamethoxazole (TMP/SMX) 160mg/800mg q12h x 1 week
Preferred if MRSA suspected or the patient is allergic to penicillin

or doxycycline 100mg bid for 1 week
*If patient is allergic to penicillin AND sulfa drugs

Warm compresses
Follow up schedule

Hospitalization for broad-spectrum IV antibiotics if:
Severe infection
Young child
Patient may be non-compliant
Any signs/symptoms of possible orbital cellulitis
No improvement with oral antibiotics

Question 8

Canaliculitis

Answer 8

Management:
Warm compress and lid massage
Broad-spectrum topical antibiotics and oral antibiotics
Topical antibiotic (e.g. tobramycin or moxifloxacin qid )
Oral antibiotic (e.g. Augmentin 500/125 mg bid, doxycycline 100 mg bid)
In severe cases, irrigation of the canaliculus with antibiotic solution.
If fungal, treat with Natamycin5% qid.
Surgery: canaliculotomy

Question 9

Acute Dacryoadenitits
Chronic>

Answer 9

Acute:
Bacterial aetiology
Augmentin (amoxicillin/ clavulanate ) 875/125mg po q12h x 1 week
Cephalexin 500mg po q12h x 1 week

Viral aetiology
Usually are self self-limiting
Oral analgesic (e.g. acetaminophen or NSAID)
If herpes suspected: oral aciclovir 400 mg (HSV) or 800mg (HZV) 5x/day

Chronic:
Treat the underlying disorder (e.g. sarcoidosis,
thyroid disease, Sjögren syndrome, lymphoma, etc.)

may be due to idiopathic inflammatory syndrome
oral steroid/ injection

Question 10

Dacryocystitis

Answer 10

Topical antibiotic (e.g. tobramycin or moxifloxacinmoxifloxacinqid )

Oral antibiotic
* Augmentin ( clavulanate ) 875/125mg q12h x 1 week
* Trimethoprim/Sulfamethoxazole (TMP/SMX) 160/800mg q12h x 1 week
* Preferred if MRSA suspected or patient is allergic to penicillin
*Doxycycline 100 mg bid x 1 week

Oral analgesic for pain (e.g. acetaminophen)
Warm compresses and gentle massage
In some cases, incision and drainage are considered
Dacryocystorhinostomy (DCR ) for chronic dacryocystitis

Question 11

Nasal lacrimal obstruction

Answer 11

Crigler massage
NLF probing at 1 year
Topical antibiotics if with discharge

Question 12

Eyelid dermatitis

Answer 12

Avoid causative agents
Cool compresses
Steroid ointment (e.g. fluorometholone 0.1 %, loteprednol 0.5%, triamcinolone 0.1%) bid for 1 week
Oral antihistamine (e.g. diphenhydramine)
Tacrolimus ointment 0.03% or 0.1% qhs or bid
Black box warning: potential risk of the development of
malignancies

Question 13

Episcleritis

Answer 13

Mild: self-limited, PF artificial tears qid

Moderate: mild topical steroid (e.g. loteprednol 0.5 % or
fluorometholone acetate 0.1% qid )

Severe: oral NSAID (e.g. ibuprofen 200 to 400 mg po bid qid
Follow-up depends on the severity
If recurrent, laboratory work up for the associated systemic condition

Question 14

Scleritis

Answer 14

Co-management by ophthalmology and rheumatology
Systemic work-up to determine the underlying cause
Oral NSAID (e.g. indomethacin)
Risk of gastric ulcers  Concurrent antiulcer medication may be needed
Oral steroid (e.g. prednisone 60 80 mg po daily for 1 week,
then tapered)
Immunosuppressive therapy (e.g methotrexate)

Question 15

Allergic conjunctivitis

Vernal

Answer 15

Mild: cool compresses, artificial tears

Moderate: Topical antihistamine/mast cell stabilizer combo

Severe
Oral antihistamine to treat both ocular and nasal symptoms
Topical steroid qid for 1 2 weeks (e.g. loteprednol 0.2% or 0.5%,fluorometholone 0.1%, prednisolone acetate 1%)
Cyclosporine 0.05% to 2% bid or qid is an alternative to steroids

Shield ulcer:
increase the dosage / potency of the steroid
Prophylactic topical antibiotic drop or ointment

Question 16

Superior Limbic keratoconjunctivitis

Answer 16

General:
Frequent PF artificial tears and lubricating ointment qhs
Bandage soft contact lens
Consider treatment with cyclosporine 0.05% b.i.d

Severe:
Short course of topical steroid

Silver nitrate 0.5% solution applied to the superior tarsal and bulbar conjunctiva with a cotton swab for 10-20 seconds.
Topical anesthetic is used before the procedure and antibiotic ointment for 1 week after

Surgery options include conjunctival cautery, cryotherapy or
conjunctival resection

Question 17

Phytenular keratoconjunctivitis

Answer 17

Topical steroid or combination antibiotic/steroid qid
(e.g. tobramycin 0.3%/dexamethasone 0.1%)
Treat blepharitis with eyelid hygiene, antibiotic
ointment for the lids
Cyclosporine is an alternative to steroid

Question 18

Staphylococcal Marginal keratitis

Answer 18

Treat blepharitis with aggressive eyelid hygiene,
antibiotic ointment for the lids
Topical combination antibiotic/steroid qid
(e.g. tobramycin 0.3%/dexamethasone 0.1%)

Question 19

Thygeson’s superficial punctate keratitis

Answer 19

Mild symptoms:
NP artificial tears 4 8x/day and lubricating ointment qhs
Moderate to severe

symptoms:
Mild topical steroid (e.g., fluorometholone 0.1% or loteprednol 0.2% qid ) for 1-4 weeks followed by a very slow taper
Consider bandage contact lens
Cyclosporine 0.05% drops qd to qid are an alternative to steroids

Question 20

Filamentary keratitis

Answer 20

Treat underlying condition
Intensive lubrication (e.g. PFATs q2h and ointment qhs
Acetylcysteine 10% (mucolytic agent) qid
Topical steroid or NSAID drops
Bandage SCL with prophylactic antibiotic
Consider debridement of the filaments

Question 21

Fuchs membrane dystrophy

Answer 21

NaCl 5% qid/ointment qhs
BCL for ruptured bullae
surgery if medical tx fails
Endothelial keratoplasty/Full thickness keratoplasty

Question 22

Anterior Uveitis

Answer 22

Thorough history and review of systems
Targeted laboratory work up
Treat underlying aetiology

Topical steroid (e.g. prednisolone acetate 1% suspension) q1-2h
*Consider a loading dose in severe cases
*Slow taper after the inflammation is resolved
*Steroid ointment at night

Cycloplegic agent (e.g. cyclopentolate , atropine) qd-tid depending on the severity
Mydriatic agent (e.g. phenylephrine 2.5% or 10%) to break synechiae
Management IOP if elevated (e.g. timolol 0.5% bid)
Follow-up schedule (freq, see on next day)

Durezol (0.05% difluprednate) QID then tapered
Very potent steroid
More likely to cause increased IOP