3: Eyelids- Infectious and Non-Infectious Disease

Question 1

normal size of palpebral fissure

Answer 1

• horizontal: ~30 mm
• vertical: ~10 mm (add marginal reflex distance-1 (distance b/t corneal reflex and UL margin) to marginal reflex distance-2 (distance between corneal reflex and LL margin))

Question 2

size of eyelid margin

Answer 2

~2mm thick and 30 mm long

Question 3

glands of Zeis:

• gland type?
• what do they secrete?

Answer 3

holocrine glands;

secrete sebum into hair follicle

Question 4

glands of Moll:

• gland type?
• what do they secrete?

Answer 4

apocrine glands;

secrete sweat into hair follicle

Question 5

papule

Answer 5

a bump, palpable and circumscribed, elevated and less than 5 mm in diameter; may be pigmented, erythematous, or flesh-toned

Question 6

macule

Answer 6

a spot, circumscribed, up to 1 cm; not palpable; not elevated above or depressed below the surrounding skin surface; hypopigmented, hyperpigmented, or erythematous

Question 7

molluscum contagiosum

Answer 7

viral infection of the epidermis

Question 8

molluscum contagiosum etiology

Answer 8

molluscum contagiosum (poxvirus); transmitted through skin to skin contact or contact with fomites

Question 9

molluscum contagiosum demographics

Answer 9

• most commonly seen in infants and children

- if seen in adults, consider immunodeficiency

Question 10

molluscum contagiosum laterality

Answer 10

unilateral or bilateral

Question 11

molluscum contagiosum symptoms

Answer 11

• bumps on skin

- mild itching of bumps

Question 12

molluscum contagiosum signs

Answer 12

• skin papules (dome-shaped bump): single or multiple, flesh-colored or pearly white, 1-2 mm in size, central umbilication due to a central keratin plug (non-ulcerative)
• if on the eyelid margin, may cause follicular conjunctivitis

Question 13

molluscum contagiosum management

Answer 13

• self-limiting within 6-12 months
• if does not self-limit or accompanied by chronic conjunctivitis, curettage for eyelid lesions (manually scraped with a curette under local anesthesia)
• cryotherapy, cautery, chemical, laser can be used for lesions elsewhere on the body

Question 14

molluscum contagiosum clinical pearls:

-immunocompromised patients may have _____

Answer 14

larger (up to 5 mm) and more numerous lesions

Question 15

impetigo

Answer 15

bacterial infection of the epidermis

Question 16

impetigo etiology

Answer 16

most commonly Staph aureus, Strep pyogenes

Question 17

impetigo demographics

Answer 17

most commonly occurs in infants and children

Question 18

impetigo laterality

Answer 18

unilateral or bilateral

Question 19

impetigo symptoms

Answer 19

• red, itchy skin rash

- may be painful

Question 20

impetigo signs

Answer 20

• skin macules (flat lesion), erythematous
• macules evolve rapidly into thin-walled blisters; when rupturing, blisters produce honey-colored (golden-yellow) crusts

Question 21

impetigo management

Answer 21

• topical antibiotic
• oral antibiotic in addition to topical
• discuss hand-washing, avoidance of eye rubbing and towel sharing, and restrict school to reduce risk of transmission

Question 22

impetigo clinical pearls:

• highly _____
• most commonly affects the _____
• can scar
• most common _____ in children

Answer 22

contagious;
the arms, legs, and around the nose and mouth;
bacterial skin infection

Question 23

hordeolum

Answer 23

• acute bacterial infection of the eyelid’s sebaceous glands with retention of oils and inflammatory debris
• external: Zeis glands
• internal: Meibomian glands

Question 24

hordeolum etiology

Answer 24

most commonly Staph aureus

Question 25

hordeolum demographics

Answer 25

no predilection

Question 26

hordeolum laterality

Answer 26

unilateral > bilateral

Question 27

hordeolum symptoms

Answer 27

- eyelid swelling (focal but may be diffuse if preseptal cellulitis is present) - pain in the area of the hordeolum

Question 28

external hordeolum signs

Answer 28

- visible or palpable nodule pointing anteriorly through the skin - erythema in the area of the hordeolum - eyelash may be at the apex of the hordeolum

Question 29

internal hordeolum signs

Answer 29

- visible or palpable nodule pointing posteriorly through the palpebral conjunctiva - injection in the area of the hordeolum

Question 30

hordeolum complications

Answer 30

- pre-septal cellulitis is commonly present | - orbital celluliltis

Question 31

hordeolum management

Answer 31

- oral antibiotic x10-14 days - warm compress with massage to express the contents of the hordeolum (at least BID, 5-10 mins of heat, massage the eyelid toward the lashes as tolerated) - lid hygiene

Question 32

hordeolum clinical pearls: | -may evolve into ____ or _____

Answer 32

``` a chalazion (post spontaneous drainage or post active infection); pre-septal cellulitis ```

Question 33

pre-septal cellulitis

Answer 33

infection of the subcutaneous tissue anterior to the orbital septum

Question 34

pre-septal cellulitis etiology/associations

Answer 34

- skin trauma (e.g., laceration, insect bite) with subsequent bacterial infection - extension from an adjacent infection (e.g., hordeolum, dacryoadenitis, dacryocystitis, sinusitis) - most commonly Staph aureus, streptococcus, H influenzae; less commonly herpes simplex, varicella zoster

Question 35

pre-septal cellulitis demographics

Answer 35

no predilection

Question 36

pre-septal cellulitis laterality

Answer 36

unilateral

Question 37

pre-septal cellulitis symptoms

Answer 37

eyelid swelling, redness, tenderness/pain

Question 38

pre-septal cellulitis signs

Answer 38

- eyelid edema, erythema with tenderness/pain on eyelid palpation - low-grade fever

Question 39

pre-septal cellulitis complications

Answer 39

orbital cellulitis

Question 40

pre-septal cellulitis management

Answer 40

- oral antibiotic x10-14 days - if moderate to severe and no improvement or worsening after 24-48 hours of oral antibiotic, refer to ER- might require IV antibiotics

Question 41

pre-septal cellulitis clinical pearls: - may develop into ____ - _____ is an ocular emergency

Answer 41

orbital cellulitis; | orbital cellulitis

Question 42

chalazion

Answer 42

- obstruction and inflammation of a meibomian gland with resultant accumulation/formation of lipogranulomatous material - anterotarsal: aka external; anterior to the tarsal plate (skin side) - retrotarsal: aka internal; posterior to the tarsal plate (conjunctiva side)

Question 43

chalazion etiology/associations

Answer 43

- commonly due to chronic blepharitis, ocular rosacea, or MGD - inflammation within MG, gland of Zeis - may have evolved from a previous hordeolum

Question 44

chalazion demographics

Answer 44

- lower socioeconomics - urban population - most common in women 10-29 years, men >60 years (but can affect all people of all ages!)

Question 45

chalazion laterality

Answer 45

unilateral > bilateral

Question 46

chalazion symptoms

Answer 46

- "bump" on eyelid: may be described as red, puffy, cyst, knot, or stye; cosmesis - painless, perhaps mild tenderness in the area of the bump - may have discharge or "drainage" - may have multiple chalazia, may have a Hx of chronic occurrences

Question 47

anterotarsal/external chalazion signs

Answer 47

visible or palpable nodule pointing anteriorly through the skin

Question 48

retrotarsal/internal chalazion signs

Answer 48

- visible or palpable nodule pointing posteriorly through the palpebral conjunctiva - must evert lid to evaluate!

Question 49

chalazion management

Answer 49

- warm compress with digital massage to express the contents (at least BID for 5-10 mins, massage lid toward lashes) - eyelid hygiene - oral doxycycline (esp in ocular rosacea or MGD) (100 mg bid x2 weeks (prominent chalazion), 50 mg bid x4 weeks, then consider 50 mg qday for another 2 months (MGD > chalazion)) - intralesional corticosteroid injection (Kenalog) - incision and curettage under local anesthesia

Question 50

chalazion clinical pearls: | -if recurs in the same location, especially with pertinent malignant findings, consider DDx of _____

Answer 50

sebaceous gland carcinoma

Question 51

blepharochalasis

Answer 51

recurrent episodes of inflammatory edema of the eyelids

Question 52

blepharochalasis etiology/associations

Answer 52

- unknown etiology | - associated with Ascher syndrome

Question 53

blepharochalasis demographics

Answer 53

- typically begins in teens-20s | - women > men

Question 54

blepharochalasis laterality

Answer 54

bilateral > unilateral

Question 55

Ascher syndrome

Answer 55

- unknown etiology - eyelid swelling (blepharochalasis), narrow horizontal palpebral fissure, lip swelling (double lip sign), euthyroid (non-toxic) goiter

Question 56

blepharochalasis symptoms

Answer 56

- painless eyelid swelling | - droopy eyelid(s) with fine wrinkles

Question 57

blepharochalasis signs

Answer 57

- eyelid edema - repeated episodes of edema may result in atrophy and laxity of the upper eyelid tissues: thin, stretched, redundant skin with fine wrinkles; ptosis; deep superior sulci; lacrimal gland prolapse

Question 58

blepharochalasis management

Answer 58

- self-limiting within a few days but can recur; with time, episodes become less frequent - no standardized treatment protocol - if redundant skin, ptosis, or lacrimal gland prolapse, consider referral out to oculoplastics for surgery (blepharoplasty or other lid restructuring surgeries)