Eyelid problems

Question 1

What are the differential diagnoses of eyelid swelling?

Answer 1

Blepharitis

Meibomian cyst (chalazion)

Stye (hordeola)

Entropion (in-turning of the eyelids)

Ectropion (out-turning of the eyelids)

Question 2

a) . What is blepharitis?
b) . What are the types of blepharitis? What are the causes?

Answer 2

a) . Blepharitis is chronic inflammation of the eyelid margins - usually BILATERAL
b) . There are 3 types which are categorised by their anatomical location:

• Anterior blepharitis
  
  • Inflammation of the base of the eyelashes
  • Caused by:
    
    • Bacteria (usually staphylococci) –> staphylococcal blepharitis
    • Seborrhoeic dermatitis –> seborrhoeic blepharitis
• Posterior blepharitis
  
  • Inflammation of the meibomian glands (often called meibomian gland dysfunction)
  • The meibomian glands secrete oil onto the eye surface to prevent rapid evaporation of the tear film. Therefore, any problem affecting the meibomian glands (as in blepharitis) can cause drying of the eyes (‘dry eye syndrome’) which in turn causes irritation
• Mixed anterior and posterior blepharitis

Question 3

Which type of blepharitis is the most common?

Answer 3

Posterior blepharitis (‘meibomian gland dysfunction’) is more common

Question 4

What conditions are frequently associated with blepharitis?

Answer 4

Dry eye disease

Seborrhoeic dermatitis

Rosacea

Question 5

Give 3 complications of blepharitis

Answer 5

Meibomian cyst

Stye

Eyelid thickening, ulceration and scarring –> entropion, ectropion

Contact lens intolerance

Dry eye syndrome

Conjunctivitis

Question 6

What are the clinical features of blepharitis?

Answer 6

Presentations:

• Symptoms are BILATERAL and intermittent, with exacerbations and remissions occurring over long periods. Worse in the morning
• Grittiness and discomfort, particularly around eyelid margins
• Burning, itching, swelling and/or crusting of the eyelids + red eyelid margins
• Eyes maybe sticky in the morning
• Styes and chalazions (more common in patients with blepharitis)
• Secondary conjunctivitis
• Contact lenses intolerance

Question 7

How do you differentiate clinically staphylococcal blepharitis from seborrhoeic blepharitis and meibomian blepharitis?

Answer 7

Eyelash loss

• Frequent in staphylococcal blepharitis but rare in the other two

Eyelash misdirection

• Frequent in severe chronic cases of staphylococcal blepharitis and rare in the other two

Eyelid and eyelash deposits

• Staphylococcal blepharitis: crusting with scales at base of eyelashes
• Seborrhoeic blepharitis: oily skin scales and greasy matted lashes
• Meibomian blepharitis: foamy discharge on lid margin

Meibomian glands

• Dilated/ visibly obstructed in meibomian blepharitis but nothing abnormal in the other two
• Meibomian cysts can be seen in meibomian blepharitis but rare in the other two

Stye

• Usually seen in staphylococcal blepharitis

Associated skin disease

• Seborrhoeic dermatitis in both seborrhoeic blepharitis and meibomian blepharitis but not seen in staphylococcal blepharitis

Question 8

Give 5 differential diagnoses of blepharitis

Answer 8

Meibomian cyst

Stye

Infection e.g. Impetigo, cellulitis or erysipelas

Psoriasis

Atopic dermatitis (eczema)

Question 9

What is the management for blepharitis?

Answer 9

Mx:

• Advise the person that blepharitis is a chronic, intermittent condition that requires ongoing maintenance treatment - cure is generally not possible
• Self-care measures such as eyelid hygiene and warm compresses twice daily
  
  • Eyelid hygiene
    
    • Mechanical removal of the debris from lid margins using a cloth or cotton bud dipped in a mixture of warm water and baby shampoo
• For posterior blepharitis, a brief gentle eyelid massage following the use of a warm compress can help improve expression of Meibomian gland secretions
• Avoid eye make-up (esp eyeliner and mascara)
• Treat associated conditions - artifical tears for dry eyes
• If eyelid measures ineffective:
  
  • For anterior blepharitis, prescribe a topical Abx (chloramphenicol) to be rubbed into the lid margin
  • For posterior blepharitis, prescribe oral Abx (doxycycline)

Question 10

When do you refer a patient with blepharitis?

Answer 10

Urgent same-day referral to ophthalmology if symptoms of corneal disease (e.g. pain, blurred vision), rapid onset visual loss, orbital and pre-septal cellulitis, or an eye becomes painful and/or red

Question 11

What is a stye (hordeolum)?

Answer 11

A stye is an acute localised infection of the eyelid margin, caused by staphylococcal aureus, and can be:

External - appears on eyelid margin, caused by infection of an eyelash follicle or associated glands

Internal - occurs on the conjunctival surface of the eyelid, caused by infection of a meibomaian gland. May leave a residual chalazion (Meibomian cyst)

Question 12

What are the risk factors for the development of a stype?

Answer 12

Chronic blepharitis

Acne Rosacea (see image) - persistent redness in the central part of your face. Small blood vessels on your nose and cheeks often swell and become visible. Swollen, red bumps.

Question 13

How long does it take for a stye to go away?

Answer 13

Symptoms usually resolve within 5-7 days, once the stye has spontaneously ruptured or been drained

Recurrence is common is there is underlying blepharitis

Question 14

Give 3 complications of a stye

Answer 14

Infective conjunctivitis

Periorbital or orbital cellulitis

Meibomian cyst (chalazion)

Question 15

What are the clinical features of a stye?

Answer 15

Acute painful localised swelling near the eyelid margin that develops over days +/- watering of the eye - usually ***unilateral

If stye is external - swelling is located around an eyelash follicle at the eyelid margin. It points anteriorly through the skin

If stye is internal - swelling is tender and localised on the internal eyelid so further away from the eyelid margin. On everting the eyelid, there is localised swelling within the tarsal plate

Question 16

Give 3 differential diagnoses of a stye

Answer 16

Meibomian cyst

Cysts of Moll - arise from blocked apocrine sweat glands on eyelid margin

Cysts of Zeis - arise from blocked sebaceous glands on eyelid margin

Contact dermatitis

Atopic eczema

Blepharitis

Malignant eyelid tumour (progressive skin lesions, distortion or destruction of the eyelid margin, loss of eyelashes, pigmentation, irregular border, ulceration, crusting or bleeding). Maybe caused by a BCC, melanoma, SCC

Question 17

How do you manage a stye?

Answer 17

Mx:

• Arrange emergency hospital admission if signs of periorbital or orbital cellulitis
• Arrange urgent referral to an ophthalmologist (to be seen within 2 weeks) if a malignant eyelid tumour is suspected
• Advice
  
  • Advise that a style is usually self-limiting and usually go away within 5-7 days
  • Apply a warm compress to the closed eyelid for 5-10 minutes twice daily until the stye drains or resolves
  • Advise the person NOT to try to puncture the stye
  • Advise to avoid eye makeup or contact lenses until the area has healed
• For a painful external stye, consider treatment in primary care for symptomatic relief:
  
  • Plucking the eyelash from the infected follicle, to facilitate drainage
  • Incision and drainage of the stye using a fine sterile needle, if appropriate
• ONLY consider prescribing topical Abx (chloramphenicol) if there are clinical features of a spreading infection causing conjunctivitis e.g. large volume of muco-purulent discharge

Question 18

What is a meibomian cyst (chalazion)?

Answer 18

It’s a *sterile (free from bacteria), inflammatory granuloma caused by obstruction of a sebaceous gland

Question 19

Describe the pathophysiology of a meibomian cyst

Answer 19

Meibomian glands are a set of glands that run along the eyelid margin, they secrete a layer of oily secretions which prevent rapid evaporation of the tear film from the eye surface

Obstruction of the gland duct causes the gland to swell and rupture, releasing its lipid contents into the surrounding soft tissues of the eyelid. This triggers a foreign body reaction (inflammatory response) against the sebum, which subsides with time. Consequently, the meibomian cyst often becomes ***painless and non-tender

It may develop acutely with a swollen red eyelid or insidiously as a firm painless nodule

Question 20

How do you differentiate a meibomian cyst from a stye clinically?

Answer 20

It’s often indistinguishable from a stye, but a meibomian cyst tends to present less acutely, less painful, and tend to have a larger swelling

Question 21

a) . A meibomian cyst is due to a bacterial infection - true or false
b) . A meibomian cyst is more painful than a stye and it presents more acutely - true or false

Answer 21

a) . FALSE - a meibomian cyst is a STERILE, inflammatory granuloma caused by obstruction of a sebaceous gland
b) . FALSE - a meibomian cyst tends to present LESS ACUTELY, LESS PAINFUL and tends to have a LARGER SWELLING!

Question 22

Give 5 risk factors of meibomian cyst

Answer 22

Chronic blepharitis

Chronic styes

Seborrhoeic dermatitis

Rosacea

Pregnancy

Diabetes mellitus

Hypercholesterolaemia

Question 23

What is the outlook of meibomian cyst?

Answer 23

Resolves spontaneously or with conservative management within weeks/ months

Question 24

Give 3 complications of Meibomian cyst

Answer 24

Astigmatism

Visual disturbance

Periorbital or orbital cellulitis

Question 25

How do you differetiate between periorbital cellulitis and orbital cellulitis?

Answer 25

Periorbital cellulitis * Infection ANTERIOR to the orbital septum * \*\*\***_Does NOT cause visual impairment, limited or painful eye movements, oedema of the conjunctiva or protrusion of the eyeball_** Orbital cellulitis * Infection POSTERIOR to the orbital septum, involving deep soft tissues surrounding the eyeball * **_Acute unilateral eyelid oedema, red painful eye, often associated with severe pain, blurred vision, double vision, limited and painful eye movements, protrusion of the eyeball, headache, and fever_** * **_MEDICAL EMERGENCY_**! * If left untreated --\> rapid loss of vision and cerebral complications e.g. brain abscess, meningitis

Question 26

What are the clinical features of a Meibomian cyst?

Answer 26

Presentations: * **_Firm, painless swelling localised to the eyelid - develops slowly over weeks_** * More commonly found on the **_upper eyelid_** and most commonly **_located away from the lid margin_** * Can affect one or both eyes * May rupture through the skin * When the eyelid is **_everted_** --\> **_well-defined, subcutaneous nodule (granuloma) in the tarsal plate_**. Erythema is usually absent

Question 27

What are the red flag symptoms that point towards a potentially serious underlying cause of eyelid swelling?

Answer 27

A firm, warm, tender, erythematous and oedematous eyelid --\> **_periorbital cellulitis or orbital cellulitis_** Recurrent meibomium cysts at the same site --\> **_meibomian gland carcinoma_**

Question 28

Give 3 differential diagnoses of meibomian cyst

Answer 28

**_Stye_** **_Blepharitis_** **_Dacryocystitis_** (infection of the lacrimal sac caused by blocked nasolacrimal duct) --\> tender, swollen, fluctuant mass located below the medial canthus. Palpation of the sac may cause expression of pus from the lacrimal puncta **_Malignant eyelid tumour e.g. BCC_**

Question 29

How do you manage meibomian cyst?

Answer 29

Mx: * Arrange **_urgent hospital admission if signs of orbital cellulitis_** * **_If red flag signs suggestive of malignancy --\> urgent referral for specialist assessment (2 week wait)_** * **_If meibomian cyst is persistent, recurrent, causing astigmatism, cosmetically unacceptable --\> refer to ophthalmology for further Mx_** * Reassure the patient that meibomian cyst is **_self-limiting_** and rarely cause complications * \*Advise the person to: * **_Apply warm compress_** to the affected eye for 10-15 minutes up to five times a day + **_gently massage the meibomian cyst_** after application of the warm compress * **_Do NOT prescribe topical/ oral Abx_** * If it does not improve or resolve after 4 weeks --\> refer to an ophthalmologist

Question 30

Describe the anatomy of the orbital septum

Answer 30

Orbital septum is **_a membranous sheet that separates the pre-septal and post-septal spaces_**. It acts as **_a barrier to infection_**. It originates both superior and inferiorly from the orbital periosteum. **_Superiorly, it's continuous with the LPS and the superior tarsal plate and inferiorly, it's continuous with the inferior tarsal plate_**

Question 31

What is peri-orbital cellulitis (AKA 'pre-septal cellulitis')?

Answer 31

Peri-orbital cellulitis is infection of the eyelid **_ANTERIOR to the orbital septum_** (this includes the eyelids, skin and subcutaneous tissues of the face, but not the orbital contents) It's much **_more common_** and **_LESS SERIOUS_** than orbital cellulitis

Question 32

What are the causes of peri-orbital cellulitis?

Answer 32

Causes of peri-orbital cellulitis: * Any skin breaks e.g. trauma, insect bites, chalazion * Local infections e.g. conjunctivitis, URTIs, **_sinusitis_**

Question 33

What are the most common causative organism for periorbital cellulitis?

Answer 33

**_Staphylococcus aureus_** Staphylococcus epidermidis

Question 34

Epidemiology of periorbital cellulitis: Which age group of people is most commonly seen with periorbital cellulitis?

Answer 34

**_Children under 10 yrs old_** More common in winter due to increased prevalence of URTIs

Question 35

What are the clinical features of periorbital cellulitis?

Answer 35

Presentations: * Red, swollen, painful eyelid * Fever but systemically well * Partial/ complete ptosis due to swelling of the eyelid * _**\*\*Absence of orbital signs**_ * No visual impairment * No limited or painful eye movements * No protrusion of eyeball (proptosis) * No oedema of the conjunctiva (chemosis) * No RAPD (Their presence would indicate orbital cellulitis, which is a medical emergency!)

Question 36

What investigations would you carry out in someone with suspected periorbital cellulitis?

Answer 36

**_Clinical diagnosis_**, however, you can do: * Bloods - raised WCC and CRP * Swab if discharge present and sent for culture * **_Contrast CT of the orbit_** - may help to differentiate between periorbital and orbital cellulitis. **_It should be performed in ALL PATIENTS suspected to have orbital cellulitis_**

Question 37

If unsure whether it's periorbital or orbital cellulitis, what Ix must you do to help you differentiate between the two?

Answer 37

Contrast CT of the orbit!

Question 38

How do you manage periorbital cellulitis?

Answer 38

Mx: * **_ALL CASES should be referred to secondary care for assessment_** * URGENT REFERRAL if suspected of orbital cellulitis or systemically unwell, or if it's a paediatric patient * Adults: * **_Oral Abx - 1st line: co-amoxiclav_** * If penicillin-allergic, give clindamycin * Children/ paediatrics: * **_Urgent referral as they require IV Abx and daily review_** (due to difficulty differentiating between orbital and periorbital cellulitis in this age group)

Question 39

Give a complication of periorbitalc cellulitis

Answer 39

Infection can spread into the orbit and cause **_orbital cellulitis_**

Question 40

What is orbital cellulitis?

Answer 40

Orbital cellulitis is infection **_POSTERIOR to the orbital septum_** - it affects the muscles and fat inside the orbit. It's a **_MEDICAL EMERGENCY_**

Question 41

Epidemiology of Orbital cellulitis: Which age group of patients is more commonly affected by orbital cellulitis?

Answer 41

**_Children_** aged 7-12 yrs old

Question 42

What are the causes of orbital cellulitis?

Answer 42

Usually caused by a spreading infection from **_acute bacterial sinusitis (most common)_** The infection spreads across the thin ethmoid bones and reach the orbital contents Other less common causes include untreated periorbital cellulitis, haematogenous spread, orbital trauma e.g. dog bite

Question 43

Give 5 risk factors for orbital cellulitis

Answer 43

**_Children_** (16-fold increase in risk!) Previous sinusitis Recent eyelid infection (periorbital cellulitis) Lack of Haemophilus influenza type b vaccination

Question 44

What are the clinical features of orbital cellulitis?

Answer 44

Presentations: * Red, swollen, painful eye (severe eye pain) * Fever * \***_Visual disturbance_** - blurred vision (reduced VA), changes in colour vision (red-green tends to be the first colours lost) * \***_Limited and painful eye movements_** * \***_Protrusion of eyeball (proptosis)_** * \***_Oedema of the conjunctiva (chemosis)_** * \***_+ RAPD (marcus-gunn pupil)_** Bilateral eye signs --\> cavernous sinus thrombosis (remember that infection forms clots) Headache, neck stiffness, photophobia --\> meningitis Headache, fever, focal neurological signs (CN3 or 6 palsy secondary to raised ICP, seizures) --\> brain abscess

Question 45

What investigations would you carry out for orbital cellulitis?

Answer 45

Ix: * **_FBC_** - raised WCC (esp neutrophilia) and CRP * **_Blood culture and microbiological swab_** (including swabs of the conjunctiva and nasopharynx) --\> usually **_staphylococcal aureus_**, **_streptococcal species_**, **_haemophilus influenzae B_** * _**\*\*\*Contrast CT of the orbit, sinuses and the brain**_ shows inflammation of the orbital tissues deep to the septum, sinusitis * **_MR venogram if suspected of cavernous sinus thrombosis_** and **_lumbar puncture if meingitis is suspected_**

Question 46

How do you manage orbital cellulitis?

Answer 46

Mx: * **_Immediate hospital admission for IV Abx + urgent referral to ophthalmology and ENT_** * **_Re-imaging with contrast CT scan is needed_** to confirm clearance of the infection * If an orbital collection is seen on imaging --\> **_drainage of orbital pus/ paranasal sinus pus is required_**

Question 47

Give 3 complications of orbital cellulitis

Answer 47

Cavernous sinus thrombosis Vision loss Brain abscess Meningitis

Question 48

What is the classification used to categorise orbital complications of acute sinusitis

Answer 48

Chandler's classification

Question 49

Tell me about the Chandler's classification How is the Mx different in each group?

Answer 49

_Chandler's classification_ Group 1 - Periorbital cellulitis Group 2 - Orbital cellulitis Group 3 - Subperiosteal abscess (abscess between bone and periosteum) Group 4 - Intraorbital abscess Group 5 - Cavernous sinus thrombosis Mx: Group 1 - treated with Oral Abx Group 2 - treated with IV Abx Group 3 & 4 - treated with surgical drainage Group 5 - treated with surgical drainage + anticoagulation