Lid disorders

Question 1

Stye (hordeolum).

a) What is a stye?
b) Risk factors
c) Presentation
d) Management

Answer 1

a) Eyelid pustule (infected)
b) Blepharitis
c) Painful yellow pus-filled spot on eyelid

d) - Self-limiting (does not need ABx)
- Warm compresses (draws pus out and eases pain)
- Avoid eye makeup/contact lenses
- Rarely, may need incision and drainage

Question 2

Chalazion.

a) What is it? (vs. a stye)
b) Risk factors
c) Presentation
d) Management

Answer 2

a) Meibomian cyst: an eyelid cyst (non-infected)
(Stye = eyelid pustule = infected)

b) Blepharitis, eczema
c) Small lump on the eyelid (usually painless); if large, may have discomfort; may get infected - becomes red/purulent; should not affect vision unless large and pressing on the eye

d) - Reassure (50% improve with no treatment)
- Eyelid hygiene: warmth (compresses to ease symptoms), massage (in the direction of the eyelashes) and cleaning
- Surgery may be indicated

Question 3

Blepharitis.

a) What is it?
b) Causes
c) Presentation
d) Management

Answer 3

a) Inflammation of the eyelids

b) Staph colonisation, meibomian dysfunction;
- RFs: seborrhoeic dermatitis, rosacea, dry eye

c) Sore eyelids; red, dry, gritty, burning; may have discharge and be stuck together in the morning (DD - conjunctivitis);
- may have flakes/scales (like dandruff);
- can lead to stye/ chalazion formation

d) - Eyelid hygiene: warmth (compresses), massage and cleaning
- Artificial tears
- If these fail - topical ABx (chloramphenicol/ fusidic acid), then oral ABx (doxycycline)

Question 4

Ptosis.

a) Innervation of levator palpebrae superioris
b) How can the pupil size help with diagnosis?

Answer 4

a) Dual innervation: oculomotor nerve and sympathetic fibres (the latter innervates a portion of the LPS called Muller’s muscle); hence, CN III palsy or sympathetic chain lesion can cause ptosis

b) - Horner’s: MIOSIS, ptosis, anhidrosis
- CN III palsy: MYDRIASIS, ptosis, down + out eye
- Normal pupils = alternative cause for ptosis (non-neuro)

Question 5

Orbital cellulitis vs. peri-orbital (preseptal) cellulitis.

a) Causes
b) Clinical features
c) Investigations
d) Management
e) Complications

Answer 5

a) - Peri-orbital: usually from local facial or eyelid injury or infection (eg. conjunctivitis); more rarely from sinuses. Most common pathogen: staph aureus
- Orbital: usually from sinusitis/ dental abscess (most common pathogen: strep pneumoniae) ; may be spread from preseptal cellulitis (more rarely)

b) - Peri-orbital: eyelid swelling, tenderness, redness or discoloration; sometimes fever; patient may struggle to open the eye, BUT… ocular movements intact (and non-painful), VA not affected, and no proptosis
- Orbital: as for peri-orbital AND… reduced eye movements, pain with eye movements, reduced VA, and proptosis (direction of proptosis may indicate source of infection - eg. ethmoid sinus would push eye laterally)

c) - VA testing, eye movements
- If worried about orbital cellulitis: CT orbit, sinuses +/- brain (MRI if worried about cavernous sinus thrombosis)
- If worried about meningitis: LP

d) - Referral: all children with preseptal cellulitis - presumed orbital UPO; anyone with suspected orbital cellulitis; systemically unwell; not responding to Rx
- Preseptal: oral co-amoxiclav (check allergies)
- Orbital: Admit to ENT, IV ABx (7-10 days of fluclox + cefotaxime)

e) - Preseptal: spread to orbital cellulitis
- Orbital: ocular (infection, raised IOP and vision loss, exposure keratopathy), abscess (orbital, subperiosteal, intracranial), meningitis, cavernous sinus thrombosis

Question 6

Horner’s.

a) Classic triad (if congenital may also have what sign?)
b) Central (1st order fibres) causes
c) Pre-ganglionic (2nd order fibres) causes
d) Post-ganglionic (3rd order fibres) causes
e) Confirming Horner’s
f) Investigations
g) What lesions classically produce an ‘incomplete’ Horner’s syndrome?

Answer 6

a) Unilateral ptosis, miosis and anhidrosis
- Congenital: hetetrochromia irides (iris colouration is under sympathetic control, occurs age 0 - 2)

b) Hypothalamus to brainstem to C8-T2 within CNS:
- CVA, MS, cervical cord trauma, syringomyelia, carotid dissection/neck trauma

c) Leave CNS at ~ level T1, to ascend towards sympathetic ganglion at C3-C4:
- Apical lung tumour, lymphadenopathy, aortic/ CCA/ subclavian aneurysm, neuroblastoma, cervical rib

d) Ascend from ~ C3 alongside the ICA, passing through the cavernous sinus into the orbit via the superior orbital fissure:
- Carotid dissection, cluster headaches, migraine, herpes-zoster, cavernous sinus thrombosis, GCA

e) Cocaine eye drops: Horner’s pupils will not dilate

f) - CXR (?Pancoast tumour, lymphadenopathy, etc.)
- CT/MRI head (?CVA, MS, etc.)
- MRI spine (?spinal cord lesion)

g) Carotid dissection:
- Only ptosis and miosis (not anhidrosis)
- Also will likely have unilateral head/neck pain +/- features of CVA

Question 7

Pancoast syndrome.

a) Most common causes
b) Presentation
c) Investigations

Answer 7

a) Usually NSCLC: adenocarcinoma and squamous cell
- Other malignancy: breast, lymphoma, metastases
- Rare: TB, pneumonia, etc.

b) - Unilateral shoulder/arm pain (+/- complex regional pain syndrome)
- Horner’s syndrome
- Weakness/wasting of the intrinsic muscles of the hand (C8 - T1)
- Less commonly: recurrent laryngeal nerve palsy (hoarse voice) and SVC obstruction

c) 1st line: CXR
- Other: CT, PET, percutaneous biopsy (lung, nodes, etc.)