Lid Lesions and more DINA M KAKISH, OD ,FAAO UNIVERSITY OF MICHIGAN Blepharitis/Meibomianitis Hordeolum/Chalazions Dacryocystitis/Dacryoadenitis Preseptal Cellulitis/Orbital Cellulitis Overview Dermatitis/Eczema Lesions Herpes Simplex/Zoster Orbital Fractures Triaging the Red Eye Case #1 25 year old male graduate C/C: itching of the eyelids with student mild redness- No discharge No watering No photophobia No vision blur No Corrective lenses Lid margin appears slightly red 1. Conjunctivitis What is your 2. Blepharitis Diagnosis and 3. Hordeolum (stye) Plan? 4. None of the above Blepharitis/Meibomianitis Signs/Symptoms Eyelid itching Flaking of eye lids Redness of lids Foreign body sensation If chronic may cause ocular surface issues (dry eye) There is an increase risk of hordeolum/chalazion Common in patients with Rosacea/ Seborrheic dermatitis Can be due or worsened by poor lid hygiene Sleeping with make up on Eyelash extensions Treatment Warm compresses 2 to 4 times daily Lid washes twice daily • Helpful in removing eye makeup and for seasonal allergies Artificial tears 4 times daily if patient has dry eye symptoms If moderate/severe may need steroid/antibiotic ointment • Maxitrol (neomycin and polymyxin B sulfates and dexamethasone) • Tobradex ( tobramycin and dexamethasone) Warm Compresses Wash your hands thoroughly Moisten a clean washcloth or paper towel with warm water Close eyes and place washcloth on eyelids for about 10 minutes (warm up again if necessary) May also use commercially available eye masks Lid Washes/Scrubs Wash and dry Wash and dry hands Mix Mix a small amount of baby shampoo with water or use commercially available solution/pads Close close one eye and gently rub solution across lids and lash line with clean cloth Rinse Rinse with cool water Repeat on Repeat on other eye- using new cloth Eyelid Demodex Eyesite.org Demodex Collerettes m.baomoi.com Treatment Tea-Tree Oil Eyelid Scrubs Eyelid Cleansers with hypochlorous acid Oral Metronidazole + Ivermectin orally was more effective then Ivermectin alone •International Journal of infectious disease •Small study Clinical trials of Ivermectin 0.1% Metronidazole 1% cream •In phase 3 clinical trials Case#2 21 years old female C/C: swollen red upper left eyelid for 2 days No redness of the eye, No Photophobia, No discharge, No tearing, No decrease in Vision Hurts when she blinks She wears contact lenses- she does Not sleep in her contacts On examination- painful to touch, erythema & edema of the upper eyelid. No redness of the eye Vision is 20/20 R 20/20 L http://optometry-today.com/hordeolum-stye/ No pain on eye movement What is your 1. Conjunctivitis Diagnosis and 2. Hordeolum Plan? 3. Preseptal Cellulitis 4. Chalazion Signs/Symptoms Pain/tender to touch May see pustule on the lid margin Hordeolum Edema and erythema of the eyelid Vision is generally not affected Conjunctiva is normally clear Treatment Treatment is dependent on severity Warm compresses 2 to 4 times daily Oral antibiotic • Dicloxacillin or Keflex • Must think about MRSA • Athletes, hospital employees Signs/symptoms Lump/bump on lid No pain/tenderness No inflammation of www.chalazion.me surrounding tissue Chalazion Treatment Warm compresses If there is no response to treatment, then removal by Ophthalmology will be need 18 year old C/C: irritation and redness of the eyes and sometime the eyes hurt No discharge, No photophobia, No itching , No decrease in vision Worse after doing near work Patient does not wear contacts or glasses Case #3 Patient is on Accutane On examination Eyes appear red at 3 and 9 O’clock Vision is 20/20 R 20/20 L No pain on eye movement Pupils -Normal What is your 1. Blepharitis Diagnosis and 2. Allergic Conjunctivitis Plan? 3. Hordeolum (stye) 4. None of the above Dry Eye Symptoms: Foreign body sensation Gritty sandy feeling in the eye Redness Tearing Pain and photophobia Causes: Eyelid issues – Meibomian gland issue Medications: antihistamines, Accutane, antidepressants Age Increase near work – 40 to 50% reduction in blink rate with any near work Treatment Artificial Tears 4 to 6 times daily Warm compresses Take Breaks when doing near work ( 20/20 rule) Restasis( cyclosporine 0.05% )/ Xiidra (lifitegrast 5%) Punctal plugs 50 year old female Case #4 C/C: excessive tearing, some irritation in the corner of the right eye No photophobia No mattering in am, no mucous discharge, no decrease vision, no itching, no redness of the eye On examination Vision 20/20 R 20/20 L Some tenderness in the nasal aspect of the lower right eyelid + epiphora No conjunctival injection EOM: full and no pain on movement EyeHealthWeb.com What is your 1. Hordeolum Diagnosis and 2. Dacryoadenitis Plan? 3. Dacryocystitis 4. None of the above Dacryocystitis Inflammation/Infection of the lacrimal Sac Discharge can be excreted from the punctum when pressure is applied Can be due to stenosis or blockage of the duct Signs/symptoms Erythema and Tenderness over the lower nasal aspect of the eyelid Epiphora Treatment Oral antibiotics •Augmentin 500/125 tid or 875/125 bid Warm compresses with gentle massage 4 times daily Needs to be referred for further evaluation, may need incision/drainage or surgical correction Case #5 21 yr old female She was seen by her Ophthalmologist in Chicago over break Dx with Hordeolum and treated with Keflex qid She has been on Keflex for 3 days with no improvement Atlas of Ophthalmology History: Is the area painful or warm to touch? No Is her vision blurred? No Fever? No Eye redness? No Previous occurrence? Yes treated and What Next? cleared with Keflex about 1 yr ago Recent hospitalizations or MRSA infections? Yes MRSA infection on forearm about 4 weeks ago Any other health issues? No No other Medications, NKDA, Non-Smoker Examination Visual acuity 20/20 R 20/20 L without correction Edema in the superior temporal area of the upper left eyelid- No pain on palpation Not warm to touch All other structures were normal What is the Diagnosis? 1.Dacryoadenitis 2.Dacryocystitis 3.Hordeolum 4.None of the above Inflammation/infection of the lacrimal gland Swelling of the lateral upper 1/3 of the eye lid If suspect infection- treat with oral Dacryoadenitis antibiotics if suspect inflammation- may need CT to rule out mass Think about autoimmune disease (Sjogren) Treatment Patient was referred to Kellogg Eye Center urgently She was seen that day- The Ophthalmologist ordered a CT CT was negative Patient was scheduled for lacrimal gland biopsy to rule out Sjogren Case #5 follow up Less than 48 hours later Patient presented to ED with pain level of 10/10 Another CT was run- + for cyst behind the orbit Patient was admitted to hospital and treated with Vancomycin IV While in the hospital – biopsy of lacrimal gland was done Preseptal Cellulitis Vs Orbital Cellulitis Preseptal Cellulitis Signs/Symptoms Tenderness, Erythema, Edema and Warmth of the eyelid and periorbital area. Often history of sinusitis, local skin abrasions, hordeolum, or insect bites. May complain of fever Treatment Oral antibiotic- must cover for MRSA • Clindamycin 300mg every 8 hours ( monotherapy) • Bactrim DS (Sulfamethoxazole/Trimethoprim) plus one of the following- Amoxicillin, Augmentin, or 3rd generation Cephalosporin (cefpodoximne) • This is to cover both MRSA and Group A strep • Tetracyclines ( Doxycycline , Minocycline) Preseptal Cellulitis Patient must be followed closely – return within 24 to 48 hours If patient is non compliant, or S/S do not improve or Worsen- must send to Emergency department Cellulitis Signs/Symptoms Erythema Tenderness Edema Proptosis Pain on eye movement EOM restriction Decrease in visual acuity Conjunctival injection Fever Treatment Refer to Emergency Department Patient will need orbital CT Patient will be admitted and given IV antibiotics Eye Lid Skin Issues Contact Dermatitis/Eczema Treatment Oral Antihistamine Steroid Cream ( Hydrocortisone 1% OTC )- • can thin the skin/discoloration • max 1 week • Usually works within 3 days Cold compresses CerAve /Cetaphil Cream or Lotion • If eczema will continue long term If treatment does not work may try antifungal cream • Usually refer to Dermatology at that point 21 year old female C/C: multiple pink eyes in the last 2 months, she was treated with antibiotic drops, gets better Case #6 than returns. In the past 4 weeks she has noticed these bumps on her lid as well She does not wear corrective lenses No pain No photophobia No decrease Vision No mattering or mucous discharge in am Some watering On Examination Vision 20/20 R 20/20 L Conjunctival injection grade 1+ Small lesions on the lower lid below the lash line Eye Physicians & Surgeons, PCEyelid Lesions What is your 1. Viral Conjunctivitis Diagnosis and 2. Mulluscum Contagiosum Plan? 3. Hordeolum (stye) 4. None of the above Treatment Removal of lesions Treat the conjunctivitis Cold compresses, artificial teas May need steroid drop Xanthelasma Scholesterol-filled yellow plaques lhigh cholesterol ( 50% association)w, soft lesUs%0%ateral https://medical-dictionary.thefreedictionary.com/xanthelasma Herpes Simplex of eye lid Treatment Send to eye care for evaluation • If suspect ocular involvement Oral antivirals for 7 to 10 days • Acyclovir 400mg 5 times a day • Famciclovir 250mg 3 times a day • Valacyclovir 1000mg 2 times a day Corneal dendritic lesions Signs/Symptoms: Photophobia Pain-if recurrence may not be Redness Tearing Treatment: Zirgan (ganciclovir) American Academy of Ophthalmology