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Home , Allergic conjunctivitis, Blepharitis

series • EDUCATION

Itchy case study Eye series – 17

Chris Hodge, BAppSc, DOBA, is Research Director, The Eye Institute, Chatswood, New South Wales. David Ng, MBBS, FRANZCO, MPH, is an ophthalmic surgeon, The Eye Institute, Chatswood, New South Wales.

Case history FEEDBACK A 45 year old woman presents with itchy, irritable eyes. She finds it is generally worse in the morning. Answer 1 Although there is no obvious Itchy, irritable eyes may represent the pres- discharge she occasionally finds ence of a number of ocular conditions: herself cleaning dandruff-like particles from her lashes. The condition is Allergic may cause such symp- intermittent in nature. In the past she toms but there would more commonly be has used over-the-counter ocular excessive discharge and redness as well. In Figure 1. Molluscus contagiosum lubricants that provide temporarily severe cases the lids will also become inflamed relief, but symptoms usually recur. and swollen. Attacks will generally occur around She is otherwise healthy with no associated health problems. the hayfever season unless a chronic situation is present. Patients may also have an allergic type history, ie. , hayfever, eczema. Question 1 Ocular surface disease such as superficial Describe the differential diagnoses. will produce symptoms of local irrita- tion and subsequent tear film disruption. Question 2 Patients will complain of a foreign body sen- Figure 2. Mebomianitis Differentiate the common types of blephari- sation and often note constant tearing. Vision tis. What ocular signs – seen upon close may or may not be affected depending on the lids) may lead to irritation and tearing. The examination – will help determine the correct origin and severity of the particular condition. symptoms are usually constant and aggravated diagnosis? Inflammatory diseases of the lids or lid further by external factors such as dry or windy margins will also disrupt the tear film surface conditions. Patients may gain temporary relief Question 3 and lead to the patient complaining of from symptoms by excessive eye rubbing. This Is it possible for this patient to go blind? burning, irritable eyes. Localised swelling of will often leave the eye red and inflamed and the lids, with or without associated crusting cause the condition to further deteriorate. Question 4 or discharge will be noticeable on close Describe the treatment options. examination. As the production of tear film is Answer 2 significantly reduced during sleeping hours, is a relatively common inflamma- Question 5 disorders that affect the stability of the tear tory condition of the lid margins. The What are the possible side effects of these film will generally be exacerbated upon condition may be classified into two main treatments? waking. Infections may include conditions types, anterior and posterior blepharitis. such as chalazions, or blepharitis, or Symptoms of both types will be similar, unusual presentations such as molluscum however, subtle differences will allow proper contagiosum, an infection due to the pox diagnosis and lead to more effective treat- class of viruses (Figure 1). ment. Anterior blepharitis may be classified Mechanical lid anomalies such as further due to the existing cause: or (inward or outward turning of the • Staphylococcal anterior blepharitis is

Reprinted from Australian Family Physician Vol. 33, No. 7, July 20044 531 Education: Ichy eyes case study

seborrhoea) (Figure 2) or alternately the for severe staphylococcal anterior blepharitis. may cause the glands to If the lid margin is very inflamed, hydrocorti- become blocked (posterior meibomianitis) sone ointment may also be applied (Figure 3). Firm massaging of the lid throughout the first week. margin may show thick, inspissated secre- In more severe cases oral tetracyclines can tions. Chronic cases may cause help resolve symptoms. Due to the nature of permanent lid thickening or scarring the condition, doses may need to be used leading to corneal and tear film changes chronically, tapered or discontinued and Figure 3. Blepharitis and exacerbation of symptoms. Systemic restarted when symptoms arise again. may be required to assist the Topical steroids may prove useful in some treatment of these cases. cases, however, usage should be minimised to prevent potentially damaging side effects. Answer 3 The patient should be counselled to follow The condition blepharitis is unlikely to lead the course of treatment fully (even though directly to blindness. However, lid changes symptoms may resolve soon after treatment such as notching, , entropian and commences) as the base infection may still ectropian may occur (Figure 4). These further be present. Figure 4. Lower lid notching changes may result in corneal and conjuncti- val inflammation and or scarring, leading Answer 5 caused by chronic infection at the base of ultimately to loss of vision. Patients using topical steroids and tetracy- the lashes. Without adequate treatment cline class drugs should be monitored for the this may lead to ulceration of the lid Answer 4 possibility of side effects. Chronic topical surface and tissue destruction. Long term Because of the chronic, intermittent nature of steroid use may lead to the formation of complications may include misdirection the condition, treatment is aimed at control- , increase the possible risk of infec- (trichiasis) or loss of lashes and scarring of ling symptoms and breaking the cycle of tion and cause a possible increase in the the lid margin. Further spread of the infec- inflammation. The following simple steps will patient’s that may lead tion may lead to chronic formation. provide effective treatment: to glaucomatous changes and peripheral On observation the lid margin will appear • regular artifical help to temporarily vision loss. Patients treated with tetracy- inflamed with small, hard scales surround- alleviate the itchy feeling, and will also clines may complain of gastrointestinal ing the base of the lashes (collarettes). serve to wash the eye removing possible symptoms such as nausea and diarrhoea. When removed they may lead to small, inflammatory agents Tetracyclines have also been associated with bleeding ulcers. may be • lid scrubs the development of increased sensitivity to seen on close examination – warm compressess serve to liquefy the light and the patient should be counselled to • Seborrhoeic anterior blepharitis will gener- meibomian secretions helping to facilitate avoid moderate to harsh sunlight and use ally leave the lashes with a waxy the expression of the clogging debris adequate protection. Sensitivity may continue appearance with the lashes often sticking – firm stroking (massage) on the for several weeks or months after the treat- together. A dandruff-like scale is present. toward the will bring the ment course has continued. Furthermore Unlike the staphylococcal type, the scales remaining debris to the surface for these drugs may interfere with the effective- are soft and do not bleed on removal. removal ness of the oral contraceptive pill. Treatment Associated skin changes due to the der- – cleansing lid margins using 5 drops of with tetracyclines is a contraindication during matitis may manifest itself in itchy baby shampoo into half a cup of cool, pregnancy. Although blepharitis is uncom- symptoms across other parts of the body boiled water (dip a cottonbud into the mon in small children, use of tetracyclines • Posterior blepharitis is generally caused by solution and scrub horizontally at within this age group may lead to limited a dysfunction of the meibomian glands. margin) bone growth and teeth discolouration and This condition may occur isolated or in – rinsing well with water will remove any should not be used. combination with the various anterior excess solution and debris. types of blepharitis or secondary to acne This process should be performed twice per Conflict of interest: none declared. AFP or . Posterior blepharitis day for 1 month then daily for a further may lead to an excess of oily, waxy secre- month. Chloramphenicol ointment may be Correspondence tions from the glands (meibomian applied to the lid margins for the first week Email: [email protected]

5323 Reprinted from Australian Family Physician Vol. 33, No. 7, July 2004