Exasperating Eyelids and the Red Eye

aka Ophthalmology Befuddler 005

A man presents with a diffusely red eye and a problem with his eyelids. You resist the urge to send out a ‘Trauma Call‘ and start wracking your brains for everything you know about eyelid disorders.

Meibomitis (posterior blepharitis)
Meibomitis (posterior blepharitis) Source: RootAtlas.com

Questions

Q1. What is the differential diagnosis of an essentially painless, but red, eye?
Answer and interpretation


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.

Q2. What is blepharitis and what are the symptoms?
Answer and interpretation

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.


Q3. What are the examination findings of blepharitis?
Answer and interpretation

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)


Q4. How is blepharitis managed?
Answer and interpretation
  • 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.


Q5. How does the timing of symptoms help distinguish dry eye syndrome from blepharitis?
Answer and interpretation

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.


Q6. What is entropion?
Answer and interpretation

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


Q7. What are the features of entropion on history and examination?
Answer and interpretation

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.



Q8. How should an entropion be managed?
Answer and interpretation
  • 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.

Q9. What is ectropion, and how does it differ to entropion?
Answer and interpretation

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

Q10. What is canaliculitis?
Answer and interpretation

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)


Q11. How is canaliculitis treated?
Answer and interpretation

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.



Q12. What is dacryocystitis?
Answer and interpretation

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.


Q13. How is dacryocystitis managed?
Answer and interpretation
  • 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.

References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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