Eyelid problems Flashcards
What are the differential diagnoses of eyelid swelling?
Blepharitis
Meibomian cyst (chalazion)
Stye (hordeola)
Entropion (in-turning of the eyelids)
Ectropion (out-turning of the eyelids)
a) . What is blepharitis?
b) . What are the types of blepharitis? What are the causes?
a) . Blepharitis is chronic inflammation of the eyelid margins - usually BILATERAL
b) . There are 3 types which are categorised by their anatomical location:
-
Anterior blepharitis
- Inflammation of the base of the eyelashes
- Caused by:
- Bacteria (usually staphylococci) –> staphylococcal blepharitis
- Seborrhoeic dermatitis –> seborrhoeic blepharitis
-
Posterior blepharitis
- Inflammation of the meibomian glands (often called meibomian gland dysfunction)
- The meibomian glands secrete oil onto the eye surface to prevent rapid evaporation of the tear film. Therefore, any problem affecting the meibomian glands (as in blepharitis) can cause drying of the eyes (‘dry eye syndrome’) which in turn causes irritation
- Mixed anterior and posterior blepharitis
Which type of blepharitis is the most common?
Posterior blepharitis (‘meibomian gland dysfunction’) is more common
What conditions are frequently associated with blepharitis?
Dry eye disease
Seborrhoeic dermatitis
Rosacea
Give 3 complications of blepharitis
Meibomian cyst
Stye
Eyelid thickening, ulceration and scarring –> entropion, ectropion
Contact lens intolerance
Dry eye syndrome
Conjunctivitis
What are the clinical features of blepharitis?
Presentations:
- Symptoms are BILATERAL and intermittent, with exacerbations and remissions occurring over long periods. Worse in the morning
- Grittiness and discomfort, particularly around eyelid margins
- Burning, itching, swelling and/or crusting of the eyelids + red eyelid margins
- Eyes maybe sticky in the morning
- Styes and chalazions (more common in patients with blepharitis)
- Secondary conjunctivitis
- Contact lenses intolerance
How do you differentiate clinically staphylococcal blepharitis from seborrhoeic blepharitis and meibomian blepharitis?
Eyelash loss
- Frequent in staphylococcal blepharitis but rare in the other two
Eyelash misdirection
- Frequent in severe chronic cases of staphylococcal blepharitis and rare in the other two
Eyelid and eyelash deposits
- Staphylococcal blepharitis: crusting with scales at base of eyelashes
- Seborrhoeic blepharitis: oily skin scales and greasy matted lashes
- Meibomian blepharitis: foamy discharge on lid margin
Meibomian glands
- Dilated/ visibly obstructed in meibomian blepharitis but nothing abnormal in the other two
- Meibomian cysts can be seen in meibomian blepharitis but rare in the other two
Stye
- Usually seen in staphylococcal blepharitis
Associated skin disease
- Seborrhoeic dermatitis in both seborrhoeic blepharitis and meibomian blepharitis but not seen in staphylococcal blepharitis
Give 5 differential diagnoses of blepharitis
Meibomian cyst
Stye
Infection e.g. Impetigo, cellulitis or erysipelas
Psoriasis
Atopic dermatitis (eczema)
What is the management for blepharitis?
Mx:
- Advise the person that blepharitis is a chronic, intermittent condition that requires ongoing maintenance treatment - cure is generally not possible
- Self-care measures such as eyelid hygiene and warm compresses twice daily
- Eyelid hygiene
- Mechanical removal of the debris from lid margins using a cloth or cotton bud dipped in a mixture of warm water and baby shampoo
- Eyelid hygiene
- For posterior blepharitis, a brief gentle eyelid massage following the use of a warm compress can help improve expression of Meibomian gland secretions
- Avoid eye make-up (esp eyeliner and mascara)
- Treat associated conditions - artifical tears for dry eyes
- If eyelid measures ineffective:
- For anterior blepharitis, prescribe a topical Abx (chloramphenicol) to be rubbed into the lid margin
- For posterior blepharitis, prescribe oral Abx (doxycycline)
When do you refer a patient with blepharitis?
Urgent same-day referral to ophthalmology if symptoms of corneal disease (e.g. pain, blurred vision), rapid onset visual loss, orbital and pre-septal cellulitis, or an eye becomes painful and/or red
What is a stye (hordeolum)?
A stye is an acute localised infection of the eyelid margin, caused by staphylococcal aureus, and can be:
External - appears on eyelid margin, caused by infection of an eyelash follicle or associated glands
Internal - occurs on the conjunctival surface of the eyelid, caused by infection of a meibomaian gland. May leave a residual chalazion (Meibomian cyst)
What are the risk factors for the development of a stype?
Chronic blepharitis
Acne Rosacea (see image) - persistent redness in the central part of your face. Small blood vessels on your nose and cheeks often swell and become visible. Swollen, red bumps.
How long does it take for a stye to go away?
Symptoms usually resolve within 5-7 days, once the stye has spontaneously ruptured or been drained
Recurrence is common is there is underlying blepharitis
Give 3 complications of a stye
Infective conjunctivitis
Periorbital or orbital cellulitis
Meibomian cyst (chalazion)
What are the clinical features of a stye?
Acute painful localised swelling near the eyelid margin that develops over days +/- watering of the eye - usually ***unilateral
If stye is external - swelling is located around an eyelash follicle at the eyelid margin. It points anteriorly through the skin
If stye is internal - swelling is tender and localised on the internal eyelid so further away from the eyelid margin. On everting the eyelid, there is localised swelling within the tarsal plate
Give 3 differential diagnoses of a stye
Meibomian cyst
Cysts of Moll - arise from blocked apocrine sweat glands on eyelid margin
Cysts of Zeis - arise from blocked sebaceous glands on eyelid margin
Contact dermatitis
Atopic eczema
Blepharitis
Malignant eyelid tumour (progressive skin lesions, distortion or destruction of the eyelid margin, loss of eyelashes, pigmentation, irregular border, ulceration, crusting or bleeding). Maybe caused by a BCC, melanoma, SCC
How do you manage a stye?
Mx:
- Arrange emergency hospital admission if signs of periorbital or orbital cellulitis
- Arrange urgent referral to an ophthalmologist (to be seen within 2 weeks) if a malignant eyelid tumour is suspected
- Advice
- Advise that a style is usually self-limiting and usually go away within 5-7 days
- Apply a warm compress to the closed eyelid for 5-10 minutes twice daily until the stye drains or resolves
- Advise the person NOT to try to puncture the stye
- Advise to avoid eye makeup or contact lenses until the area has healed
- For a painful external stye, consider treatment in primary care for symptomatic relief:
- Plucking the eyelash from the infected follicle, to facilitate drainage
- Incision and drainage of the stye using a fine sterile needle, if appropriate
- ONLY consider prescribing topical Abx (chloramphenicol) if there are clinical features of a spreading infection causing conjunctivitis e.g. large volume of muco-purulent discharge
What is a meibomian cyst (chalazion)?
It’s a *sterile (free from bacteria), inflammatory granuloma caused by obstruction of a sebaceous gland
Describe the pathophysiology of a meibomian cyst
Meibomian glands are a set of glands that run along the eyelid margin, they secrete a layer of oily secretions which prevent rapid evaporation of the tear film from the eye surface
Obstruction of the gland duct causes the gland to swell and rupture, releasing its lipid contents into the surrounding soft tissues of the eyelid. This triggers a foreign body reaction (inflammatory response) against the sebum, which subsides with time. Consequently, the meibomian cyst often becomes ***painless and non-tender
It may develop acutely with a swollen red eyelid or insidiously as a firm painless nodule
How do you differentiate a meibomian cyst from a stye clinically?
It’s often indistinguishable from a stye, but a meibomian cyst tends to present less acutely, less painful, and tend to have a larger swelling
a) . A meibomian cyst is due to a bacterial infection - true or false
b) . A meibomian cyst is more painful than a stye and it presents more acutely - true or false
a) . FALSE - a meibomian cyst is a STERILE, inflammatory granuloma caused by obstruction of a sebaceous gland
b) . FALSE - a meibomian cyst tends to present LESS ACUTELY, LESS PAINFUL and tends to have a LARGER SWELLING!
Give 5 risk factors of meibomian cyst
Chronic blepharitis
Chronic styes
Seborrhoeic dermatitis
Rosacea
Pregnancy
Diabetes mellitus
Hypercholesterolaemia
What is the outlook of meibomian cyst?
Resolves spontaneously or with conservative management within weeks/ months
Give 3 complications of Meibomian cyst
Astigmatism
Visual disturbance
Periorbital or orbital cellulitis
How do you differetiate between periorbital cellulitis and orbital cellulitis?
Periorbital cellulitis
- Infection ANTERIOR to the orbital septum
- ***Does NOT cause visual impairment, limited or painful eye movements, oedema of the conjunctiva or protrusion of the eyeball
Orbital cellulitis
- Infection POSTERIOR to the orbital septum, involving deep soft tissues surrounding the eyeball
- Acute unilateral eyelid oedema, red painful eye, often associated with severe pain, blurred vision, double vision, limited and painful eye movements, protrusion of the eyeball, headache, and fever
-
MEDICAL EMERGENCY!
- If left untreated –> rapid loss of vision and cerebral complications e.g. brain abscess, meningitis
What are the clinical features of a Meibomian cyst?
Presentations:
-
Firm, painless swelling localised to the eyelid - develops slowly over weeks
- More commonly found on the upper eyelid and most commonly located away from the lid margin
- Can affect one or both eyes
- May rupture through the skin
- When the eyelid is everted –> well-defined, subcutaneous nodule (granuloma) in the tarsal plate. Erythema is usually absent
What are the red flag symptoms that point towards a potentially serious underlying cause of eyelid swelling?
A firm, warm, tender, erythematous and oedematous eyelid –> periorbital cellulitis or orbital cellulitis
Recurrent meibomium cysts at the same site –> meibomian gland carcinoma
Give 3 differential diagnoses of meibomian cyst
Stye
Blepharitis
Dacryocystitis (infection of the lacrimal sac caused by blocked nasolacrimal duct) –> tender, swollen, fluctuant mass located below the medial canthus. Palpation of the sac may cause expression of pus from the lacrimal puncta
Malignant eyelid tumour e.g. BCC
How do you manage meibomian cyst?
Mx:
- Arrange urgent hospital admission if signs of orbital cellulitis
- If red flag signs suggestive of malignancy –> urgent referral for specialist assessment (2 week wait)
- If meibomian cyst is persistent, recurrent, causing astigmatism, cosmetically unacceptable –> refer to ophthalmology for further Mx
- Reassure the patient that meibomian cyst is self-limiting and rarely cause complications
- *Advise the person to:
- Apply warm compress to the affected eye for 10-15 minutes up to five times a day + gently massage the meibomian cyst after application of the warm compress
-
Do NOT prescribe topical/ oral Abx
- If it does not improve or resolve after 4 weeks –> refer to an ophthalmologist
Describe the anatomy of the orbital septum
Orbital septum is a membranous sheet that separates the pre-septal and post-septal spaces. It acts as a barrier to infection. It originates both superior and inferiorly from the orbital periosteum. Superiorly, it’s continuous with the LPS and the superior tarsal plate and inferiorly, it’s continuous with the inferior tarsal plate
What is peri-orbital cellulitis (AKA ‘pre-septal cellulitis’)?
Peri-orbital cellulitis is infection of the eyelid ANTERIOR to the orbital septum (this includes the eyelids, skin and subcutaneous tissues of the face, but not the orbital contents)
It’s much more common and LESS SERIOUS than orbital cellulitis
What are the causes of peri-orbital cellulitis?
Causes of peri-orbital cellulitis:
- Any skin breaks e.g. trauma, insect bites, chalazion
- Local infections e.g. conjunctivitis, URTIs, sinusitis
What are the most common causative organism for periorbital cellulitis?
Staphylococcus aureus
Staphylococcus epidermidis
Epidemiology of periorbital cellulitis:
Which age group of people is most commonly seen with periorbital cellulitis?
Children under 10 yrs old
More common in winter due to increased prevalence of URTIs
What are the clinical features of periorbital cellulitis?
Presentations:
- Red, swollen, painful eyelid
- Fever but systemically well
- Partial/ complete ptosis due to swelling of the eyelid
- _**Absence of orbital signs_
- No visual impairment
- No limited or painful eye movements
- No protrusion of eyeball (proptosis)
- No oedema of the conjunctiva (chemosis)
- No RAPD
(Their presence would indicate orbital cellulitis, which is a medical emergency!)
What investigations would you carry out in someone with suspected periorbital cellulitis?
Clinical diagnosis, however, you can do:
- Bloods - raised WCC and CRP
- Swab if discharge present and sent for culture
- Contrast CT of the orbit - may help to differentiate between periorbital and orbital cellulitis. It should be performed in ALL PATIENTS suspected to have orbital cellulitis
If unsure whether it’s periorbital or orbital cellulitis, what Ix must you do to help you differentiate between the two?
Contrast CT of the orbit!
How do you manage periorbital cellulitis?
Mx:
-
ALL CASES should be referred to secondary care for assessment
- URGENT REFERRAL if suspected of orbital cellulitis or systemically unwell, or if it’s a paediatric patient
- Adults:
- Oral Abx - 1st line: co-amoxiclav
- If penicillin-allergic, give clindamycin
- Children/ paediatrics:
- Urgent referral as they require IV Abx and daily review (due to difficulty differentiating between orbital and periorbital cellulitis in this age group)
Give a complication of periorbitalc cellulitis
Infection can spread into the orbit and cause orbital cellulitis
What is orbital cellulitis?
Orbital cellulitis is infection POSTERIOR to the orbital septum - it affects the muscles and fat inside the orbit. It’s a MEDICAL EMERGENCY
Epidemiology of Orbital cellulitis:
Which age group of patients is more commonly affected by orbital cellulitis?
Children aged 7-12 yrs old
What are the causes of orbital cellulitis?
Usually caused by a spreading infection from acute bacterial sinusitis (most common)
The infection spreads across the thin ethmoid bones and reach the orbital contents
Other less common causes include untreated periorbital cellulitis, haematogenous spread, orbital trauma e.g. dog bite
Give 5 risk factors for orbital cellulitis
Children (16-fold increase in risk!)
Previous sinusitis
Recent eyelid infection (periorbital cellulitis)
Lack of Haemophilus influenza type b vaccination
What are the clinical features of orbital cellulitis?
Presentations:
- Red, swollen, painful eye (severe eye pain)
- Fever
- *Visual disturbance - blurred vision (reduced VA), changes in colour vision (red-green tends to be the first colours lost)
- *Limited and painful eye movements
- *Protrusion of eyeball (proptosis)
- *Oedema of the conjunctiva (chemosis)
- *+ RAPD (marcus-gunn pupil)
Bilateral eye signs –> cavernous sinus thrombosis (remember that infection forms clots)
Headache, neck stiffness, photophobia –> meningitis
Headache, fever, focal neurological signs (CN3 or 6 palsy secondary to raised ICP, seizures) –> brain abscess
What investigations would you carry out for orbital cellulitis?
Ix:
- FBC - raised WCC (esp neutrophilia) and CRP
- Blood culture and microbiological swab (including swabs of the conjunctiva and nasopharynx) –> usually staphylococcal aureus, streptococcal species, haemophilus influenzae B
- _***Contrast CT of the orbit, sinuses and the brain_ shows inflammation of the orbital tissues deep to the septum, sinusitis
- MR venogram if suspected of cavernous sinus thrombosis and lumbar puncture if meingitis is suspected
How do you manage orbital cellulitis?
Mx:
- Immediate hospital admission for IV Abx + urgent referral to ophthalmology and ENT
- Re-imaging with contrast CT scan is needed to confirm clearance of the infection
- If an orbital collection is seen on imaging –> drainage of orbital pus/ paranasal sinus pus is required
Give 3 complications of orbital cellulitis
Cavernous sinus thrombosis
Vision loss
Brain abscess
Meningitis
What is the classification used to categorise orbital complications of acute sinusitis
Chandler’s classification
Tell me about the Chandler’s classification
How is the Mx different in each group?
Chandler’s classification
Group 1 - Periorbital cellulitis
Group 2 - Orbital cellulitis
Group 3 - Subperiosteal abscess (abscess between bone and periosteum)
Group 4 - Intraorbital abscess
Group 5 - Cavernous sinus thrombosis
Mx:
Group 1 - treated with Oral Abx
Group 2 - treated with IV Abx
Group 3 & 4 - treated with surgical drainage
Group 5 - treated with surgical drainage + anticoagulation
