Exasperating Eyelids and the Red Eye

This can be caused by conjunctivitis, but there is usually at least some degree of discomfort. Otherwise the main causes are eyelid disorders such as:

• blepharitis, canaliculitis, dacryocystitis,
• ectropion and entropion
• trichiasis (malaligned eyelashes that irritate the eye)
• eyelid lesions, such as chalazion/hordeolum and malignancies.

Inflammation of the eyelids characterised by:

• itching, burning, mild pain or a foreign body sensation
• tearing
• crusting around the eyes on awakening.

Blepharitis usually refers to anterior blepharitis, which affects the anterior part of the eye lid and is often related to staphylococcal infection or seborrheic dermatitis. Posterior blepharitis is also known as meibomitis.

The key finding is: Thick red and crusted eyelid margins with prominent blood vessels

Other findings include:

• coexistent meibomitis — inspissated oil glands at the eyelid margins
• Conjunctival injection, swollen eyelids, and mild mucous discharge may be present.
• Superficial punctate keratopathy (SPK) or even corneal infiltrates are present in some cases.

Meibomian gland dysfunction causing blepharitis (RootAtlas)

• regular lid hygiene — e.g. scrub the eyelid margins twice a day with mild shampoo (like Johnson’s baby shampoo) on a cotton-tipped applicator or a wash cloth.
• Warm compresses for 15 minutes up to qid
• use artificial tears for coexistant dry eyes
• consider chloramphenicol 1% eye ointment topically to the lid margins, once or twice daily until clinically resolved (efficacy of topical antibiotics in blepharitis is uncertain).
• unresponsive meibomitis or ocular rosacea may require long courses (e.g. months) of oral doxycycline (has an anti-inflammatory effect) and cyclosporin eye drops.

On rare occasions the condition is intractable because there is sebaceous gland carcinoma of the eyelid.

Arrange ophthalmology follow up for about 1 month after treatment is started — blepharitis tends be a chronic problem.

In blepharitis, symptoms and crusting are usually worse at the start of the day. In dry-eye syndrome symptoms are usually worse later in the day.

Entropion occurs when a lid turns inward and is at risk of causing a corneal abrasion.

History: ocular irritation, tearing, redness, foreign body sensation.

Consider other causes:

• involutional (aging)
• cicatrical (scarring from trauma, surgery or chemical burns)
• spastic (e.g. ocular irritation)
• congenital

Examination:

• Slit lamp — use fluorescein to detect conjunctival injection, SPK, and a corneal abrasion.

• If the cornea is intact, the eye should be lubricated and the patient referred to an ophthalmologist.
• Start topical antibiotics if SPK is present.
• If there is a corneal defect the eyelid should be taped back away from the cornea, the corneal defect is managed as a corneal abrasion, and referral to ophthalmology made. Surgery may be needed for definitive treatment.

Ectropion is out-turning of an eyelid that can result in exposure keratopathy. But otherwise the treatment and causes are similar to entropion, with the addition of these causes:

• paralytic — e.g. CN7 palsy
• mechanical — e.g. orbital fat herniation or a tumor
• allergic

Tearing, a red eye, and mild tenderness over the nasal aspect of the lower or upper eyelid due to an inflamed of the canalicus. A key feature is an inflamed punctum, from which there may be mucopurulent discharge.

What’s a punctum you ask?

Anatomy of the lacrimal punctum (RootAtlas)

Send a swab of the punctal discharge to the lab as causes include Actinomyces israeli, bacteria, fungi and viruses as well retained mucous plugs.

Treat by:

• removal of concretions
• application of warm compresses
• topical antibiotics (may need to be changed following cultures)
• arrange ophthalmology follow up in a week. Elective canaliculotomy may be required.

Painful swelling of the lacrimal sac in the innermost aspect of the lower eyelid. It is usually related to nasolacrimal duct obstruction and secondary infection by staphylococci, streptococci and diphtheriae.

• Send off a swab to the lab for MCS.
• Administer oral antibiotics:
  flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly
  (cephalexin is an alternative)
• Consider  IV antibiotics (e.g. cephazolin) if febrile and acutely ill.
• Treat with analgesia and warm compresses.
• Refer to ophthalmology — a pointing abscess may be incised and drained. When chronic, surgery may be required.

• Ehlers JP, Shah CP, Fenton GL, Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease Lippincott Williams & Wilkins
• NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide. [Free PDF]