PHOTO ROUNDS Kimia Ziahosseini, MD 5 cases, 1 cause Stockport Eye Centre, Stepping Hill Hospital, Stockport, Cheshire, of irritated eyes United Kingdom rritated and watery eyes. Mild ery- of his left eye that had been bothering him [email protected] thema of the nasal bulbar conjunc- for the last 2 weeks. He had been treated Thabit A. Mustafa Odat, tiva. Photophobia. Blurred vision. with a topical antibiotic, but showed no MBBS, FRCS, JBO I Oculoplastic and Orbital These were just some of the signs and improvement. Surgeon, King Hussein Medical symptoms that prompted the following CASE 4 A 15-year-old girl came in com- Centre, Amman, Jordan 5 patients to seek treatment. Though plaining of irritation of the left eye over f E a TU r E E d ITO r the specifics of their cases varied, their the last month. She was seen by an oph- Richard P. Usatine, MD diagnosis was the same. thalmologist, who attributed her symp- University of Texas Health CASE 1 A 35-year-old man presented toms to exposure keratopathy due to lag- Science Center at San Antonio with a foreign-body sensation and tear®- Dowdenophthalmos—inability Health to close,Media or poor ing of his right eye that had lasted for a closure of, the eyelids (FIGURE). He treated few days. The eye showed mild erythema her with different lubricants and antibiot- of the nasal bulbar conjunctivaCopyright andFor linear personalics, without improvement. use only corneal abrasions. CASE 5 A 15-year-old boy came in com- CASE 2 A 23-year-old woman came in plaining of blurred vision in his right eye. complaining of an irritated and watery His ophthalmic history was significant for eye that had been bothering her for the corneal abrasion following a vague his- past 24 hours. She had normal visual tory of trauma to that eye a month ago. acuity, bulbar conjunctival injection, His best corrected visual acuity in that eye and linear corneal abrasions. was 20/60. CASE 3 A 28-year-old man presented with irritation, photophobia, and redness z What is your diagnosis? fIGUrE Eye irritation attributed to exposure keratopathy An ophthalmologist attributed this 15-year-old’s irritation of the left eye to exposure keratopathy due to lagophthal- mos—inability to close, or poor closure of, the eyelids. (The green color is fluorescein dye.) Treatment with various lubricants and antibiotics provided no relief. www.jfponline.com VOL 56, NO 5 / MaY 2007 365 For mass reproduction, content licensing and permissions contact Dowden Health Media. ROUNDS Diagnosis Meibomian gland: z Misplaced eyelash An uncommon spot The life cycle of eyelashes is usually an as- Cilia in the meibomian gland is unusual. PHOTO ymptomatic process. Sometimes, though, Clinicians who suspect this is the cause lashes can find their way into unusual of a patient’s discomfort will need to dif- anatomical sites, as occurred in the 5 cas- ferentiate it from acquired distichiasis, es described on the previous page. Here, which is metaplastic eyelash growth that broken down by the location in which the results from chronic lid inflammation. eyelash was found, is a discussion of the Careful examination, and the absence of trouble a misplaced eyelash can cause. resistance on removal, differentiate the 2 conditions. In CaSE 3, involving the 28-year-old Punctum: Upper is more common man with eye irritation and photosensi- than lower tivity, an examination showed an eyelash Once an eyelash is shed into the external protruding from a meibomian gland ori- ocular surface, it can cause foreign body fice 2 mm lateral to the lower punctum. sensation, leading to reflex tearing that He also had corneal punctate epithe- will carry it away to the lacus lacrima- lial erosions and mild ciliary flush. His lis. At this point, it comes in close contact physician removed the eyelash with for- with the punctum and can be propelled ceps without resistance. He was given a by the lids or sucked into the canaliculus topical antibiotic. in the blink cycle. In CaSE 4, involving the 15-year- If it finds its way into the punctum, old pictured on page 365 who had been the barbs on the hair prevent it from be- unsuccessfully treated with different lu- ing expelled. They can obstruct the cana- bricants and antibiotics for exposure liculi, causing epiphora, or incite inflam- keratopathy, an examination revealed mation and possibly infection, causing shortening of the upper and lower eye- canaliculitis or dacryocystitis.1 lids of the affected eye and abnormal up- FAST TRACK Eyelashes are often reported to per eye lid contour causing 4 to 5 mm of Researchers enter the upper and lower punctum, lagophthalmos. She had a positive Bell’s though Nagashima and Kido found phenomenon and normal tear break-up found that cilia in that cilia in upper punctum was 3 times time. the upper punctum more frequent than cilia in the lower Further examination of the up- was 3 times more punctum.2 per eyelid margin, pictured at far right, frequent than In CaSE 1, involving mild erythema showed a cilium projecting out of a mei- of the nasal bulbar conjunctiva and bomian gland orifice toward the ocular cilia in the linear corneal abrasions, the 35-year- surface with corneal punctuate erosions. lower punctum old patient had an eyelash protruding The eyelash was removed smoothly with from the upper punctum. The rest of the forceps without resistance, and her symp- exam was unremarkable. His physician toms resolved within a few days. removed the eyelash mechanically, with- out resistance. This relieved his symp- toms and he was given a prophylactic Corneal stroma: Suspect trauma topical antibiotic. Spontaneously or after trauma, loose In CaSE 2, the 23-year old woman eyelashes can penetrate the anterior ocu- with bulbar conjunctival injection and lar surface layers by their pointed tip.3,4 linear corneal abrasions, there was an These dislodged eyelashes can cause no eyelash projecting out of the lower punc- symptoms at all, or cause foreign body tum. The eyelash was removed easily and sensation, reflex tearing, and localized she, too, was treated with topical anti- erythema mimicking other ocular condi- biotic ointment. tions. Moreover, eyelashes can be washed 366 VOL 56, NO 5 / MaY 2007 THE JOURNAL OF FAMILY PRACtICE Misplaced eyelash casE 1 casE 2 Upper punctum Lower punctum Eyelash protruding from the upper punctum. Eyelash projecting out of the lower punctum. casE 3 casE 4 Meibomian gland near Meibomian gland lower punctum FAST TRACK Considering the history of trauma, the cilium was Closer examination of patient shown on page 365 revealed an eyelash projecting out of a meibomian gland probably Eyelash protruding from a meibomian gland orifice orifice toward the ocular surface with corneal punctuate 2 mm lateral to the lower punctum. erosions. mechanically embedded on the cornea at casE 5 the time of injury Corneal opacity Corneal opacity containing a horizontally lying eyelash. www.jfponline.com VOL 56, NO 5 / MaY 2007 367 out into the lower drainage system where they can cause tear stagnation and act as a nidus for dacryolith.5 Coming soon in Considering the history of trauma in CaSE 5, we believe the cilium was mechanically embedded on the cornea at the time of injury and got buried as Photo Rounds the surface reepithelialized. Examination revealed a corneal opacity containing a horizontally lying cilium. The patient was After Hurricane Katrina in August 2005, referred to a cornea specialist for further management. this patient was forced to wade through the polluted waters of New Orleans for many hours z When to suspect before being rescued by boat. Four days passed a misplaced eyelash It’s important to examine the eyelid mar- before she had access to a shower. It was after gin carefully in patients with nonspecific this shower that she first noticed a single eye symptoms, as misplaced eyelashes can be easily overlooked and treated erythematous lesion the size of a silver dollar on inappropriately. Moreover even in the her left thigh. The lesion then faded to hypo- presence of an obvious pathology, be sure to look for associated findings, especially pigmented macules and plaques. Over time, the when that pathology cannot fully explain rash spread to both thighs and arms. She does the symptoms. That was especially im- portant in Case 4, with the rare occur- not have any itching, pain, bleeding, fever, chills, rence of exposure keratopathy in a young weight changes, or GI symptoms. patient. n Correspondence Kimia Ziahosseini, MD, Flat 5, 25 Higher Hill Gate, Stockport, Cheshire SK1 3ED United Kingdom. Could the [email protected] flood waters Disclosure of Katrina No potential conflict of interest relevant to this article be resposible was reported. for this References condition? 1. Duke-Elder S. System of Ophthalmology. Vol 13. London: Henry Kimpton; 1974. 2. Nagashima K, Kido R. Relative roles of upper and lower lacrimal canaliculi in normal tear drainage. Jpn J Ophthalmol 1984; 28:259–262. 3. Taneja S, Arora R, Yadava U. Fingernail trauma causing corneal laceration and intraocular cilia. Arch Ophthalmol 1998; 116:530–531. 4. Oh KT, Oh KT, Singerman LJ. An eyelash in the THE JOURNAL OF vitreous cavity without apparent etiology. Ophthal Surg Lasers 1996; 27:243–245. FAMILY 5. Rosen WJ, Rose GE. Intranasal passage of dacryo- PRACTICE liths. Br J Ophthalmol 2000; 84:799–800. www.jfponline.com.