Lecture 7- Eyelids Part 2

Question 1

Most common form of blepharitis

Answer 1

squamous - non purulent - with increased marginal hyperemia and telangectasia- squamous types have a hypersensitivity component - pollutants, makeup, soaps etc

Question 2

Most common bacteria in and around the eyes

Answer 2

Stachylococcus - gram + noncapsulated spheroidal bacteria - always on lid margin

Question 3

Most common strains associated with eye conditions - strains of the most common bacteria on lids

Answer 3

Staph. Aureus and Staph. Epidermidis

Question 4

Staph is the leading cause of marginal infiltrative keratitis, BUT what bacteria are more aggressive, more frequent proliferation, and cause more inflammatory reaction?

Answer 4

Streptococcus - and other gram positive bacterium

Question 5

Toxin produced by staphylococcus aureus that causes a dermonecrosis, irritates occular surface - stimulating immune- inflammatory response

Answer 5

Alpha- Toxin

Question 6

hyperacute forms of blepharitis with heavy discharge and preseptal cellulitis (for example) are caused by which bacteria

Answer 6

Streptococcus - G+, and some G-

Question 7

condition caused by infection of eyelid margin- lash follicles and MG’s, become edematous and erythematous-greasy scales, lashes become crusted with dried serous fluid, typically caused by s. Aureus/epidermidis, or HSV/VZV, rapid onset/short duration, prevalent in warmer climates, affects middle aged females, related hordeolum/chalzion/SPK, cause preseptal cellulitis

Answer 7

Acute Marginal Blepharitis

Question 8

condition involving poor hygeine and yellow pustules and gold crusts, could be mistaken for Acute Marginal Blepharitis, so you need to look for vesicles on the skin.

Answer 8

Impetigo

Question 9

How to treat Acute Marginal Blepharitis

what happens if you remove the crusts?

Answer 9

lid hygiene 2-8 weeks BID to QID- hot compress, lid scrubs, baby shampoo diluted w water, Tea tree oil or cetaphil, Blephex, artifical tears for dry eye, antibiotics

Question 10

What antibiotics should be employed for treatment of Actute Marginal Blepharitis?

Answer 10

Ointments - Bacitracin and EEM - staph Aureus/epidermidis
Lid scrubs with Gentamycin and tobramycin - aminoglycosides
Sulfonamides but 70% of staph not affected
Broad spectrum- Azythromycin - not as effective, no effect on MRSA
Trimethoprim.polyminB are effective
AB/steroid combo like genta/dexa, Tobradex, zylet,

Question 11

AB with dual action anti-inflammatory, with Durasite vehicle, 1 drop bid x 2 days, then 1 drop 2-4 weeks, use for bacterial conjunctivitis

Answer 11

Azasite - topical medication for Acute Marginal Blepharitis

Question 12

If a patient used Azasite for 4 week and is not seeing any improvement, start systemic antibiotics for MRSA and other infections. Which ABs could be used?

Answer 12

Doxycycline - 100 mg bid for 7-10 days (other strengths and duration for other conditions)
EES - 400 mg 4/day for 1-4 weeks
NO TETRACYCLINE OR DOXCICLINE in pregnant/nursing or kids under 8, Erythromycin 200 mg BID can be used instead

Question 13

T or F: meibomian glands become clogged in posterior blepharitis only if there is rosacea present?

Answer 13

FALSE : Meibomian glands get clogged in posterior blepharitis, whether rosacea is present or not!

Question 14

Condition marked by posterior lid margin redness, often seen in patients with MGD, indicated by crusting on anterior lashes, can lead to chrnoc conjunctivitis, madarosis, and tylosis- thickened lid margin, Treated with hygiene and ABs

Answer 14

Mixed Blepharitis- “mixed” often indicated by crusting on anterior lashes, Blepharitis MIXED with MGD

Question 15

What is the difference between and External and Internal Hordeolum in terms of location and appearance, and which more often causes preseptal cellulitis

Answer 15

External Hordeolum: Zeis and Moll glands, with Head

Internal Hordeolum: Meibomian glands, no Head, more often preseptal cellulitis

Question 16

Type of hordeolum more common in children and young adults, due to acute staph infection of Zeiss or Moll glands, lash at apex, associated with staph blepharitis- change makeup/mascara every 3 months, poor diet, fatigue, stress, can lead to preseptal cellulitis, how is it treated?

1. Name
2. normal course- how to hasten progression
3. How to prevent further infection of area
4. Tx if severe inflammation
5. How to further assist drainage
6. What if lesion is resistant to topical ABs
7. what if infection or PAN lymphadenopathy
8. if condition is recurrent? - pharmacological
9. If condition is recurrent? - test

Answer 16

1. External Hordeolum
2. Self limiting - 5-7 days - hot compress to hasten drainage/pointing
3. Topical antibiotics to prevent infection of surrounding follicles - Bacitracin, Erythromycin
4. Topical steroid if severe inflammation
5. Epilate 1 or 2 of involved lashes to create drainage
6. If lesion is resistant, incision with blade, topical AB - tobramycin or bacitracin/polymycin B
7. systemic antibiotics if infection elsewhere or + PAN lymphadenopathy - EEM, Doxy, Diclo, Tetra, Amox - TID - best for kids but tastes bad
8. If recurrence - Tetracycline or Doxycycline for several months
9. Obtain lid culture for recurrent hordeolum to institute specific AB

Question 17

Localized staphylococcal infection of the meibomian gland, can be from blockage, found in upper tarsus usually, diffuse swelling, preseptal cellulitis greater risk, recurrence associated with IgM deficiency and abnormal triglycerides

1. name
2. treatment if mild
3. tx if moderate
4. if mild PCN allergy
5. if True PCN allergy
6. Second line therapy
7. are VA affected
8. Most common eyelid lesion acquired by what population
9. Follow up how often
10. if cases are resistant to ABs
11. What is needed if recurrent or unusual - test
12. What if cellulitis develops

Answer 17

1. Internal Hordeolum
2. mild- hot compresses several times a day
3. moderate - oral AB - doxycycline 100mg, dicloxacillin 250
4. for mild PCN allergy, 1 or 2 en cephalosporin like cephalexin or cefuroxime
5. true PCN allergy - lovofloxacin
6. second line therapy - oral EEM, TTC, or Amox for 10 days
7. VA usually not affected unless causing distortion of cornea
8. most common eyelid lesions acquired in children
9. follow up every week until resolved
10. incision and drainage, injection of steroid - triamcinolone, lidocaine with epinephrine to open vessels for faster action,
11. Biopsy
12. IV antibiotics referral

Question 18

What is the most common misdiagnosis of a hordeolum?

Answer 18

Chalazion - which is NOT painful, but Hordeolum are

Question 19

Why should HIV be considered in young pt with atypical hordeolum?

Answer 19

Occult HIV because Kaposi sarcoma can mimic a hordeolum

Question 20

Why do recurrent lesions with madarosis require a biopsy?

Answer 20

Need to rule out Sebaceous Cell Carcinoma

Question 21

Uncommon superficial skin infection by staph or strep, typically if skin barrier is broken, contagious if fluid that oozes from blisters touches an open area on skin. MRSA is becoming a common cause. most common in children in unhealthy living conditions. in adults, may follow other skin disorders or URTI, only involves top layer of skin, yellow fluid, pus filled blisters that leave a raw base, + lymphadenopathy in adjacent nodes

1. Disease
2. how to treat/ hygiene
3. pharm tx
4. tx for mild infection
5. if caused by S pyogenes
6. severe cases tx
7. tx for severe localized cases, causes skin photosensitivity not for kids under 8
8. complications
9. Prevention

Answer 21

1. Impetigo
2. no sharing towels, clothes, razors, personal care products, wash hands with clean washcloth, wash skin with AB soap several times per day
3. Hydrogen peroxide 1% cream 2/3x per day for 3 weeks
4. mild - Bactroban or mupirocin 2/3/day for 7 days, Fusidic Acid in europe but not in USA
5. caused by S. pyogenes - Retapamulin (altabax)
6. oral antibiotics - Clindamycin/Gentamycin
7. Tetracycline
8. scar, spread, post infection glomerulonefritis
9. good hygiene, clean minor cuts and scrapes well with soap and clean water

Question 22

Holy Fire: Uncommon acute subcutaneous cellulitis by S aureus or strep pyogenes through minor skin trauma or pharyngitis. Well demarcated erythematous subcutaneous plaque, involved upper dermis and extends into superficial cutaneous lymphatics, primary lid involvement, fever, malaise, pruritis, burning, swelling, tender.

1. Name
2. risk factors
3. treatment- for condition, fever, ulceration, severe infection
4. if severe, tx, if allergic to PCN

Answer 22

1. Erysipela
2. 60-80 y/o, immunocomrpomised-DM, lymphatic drainage problems - after surgery, homeless
3. ABs usually, hydration and cold compress for fever, saline wet dressings for ulcerated or necrotic lesions, debridement if severe infections
4. hospitalize, oral phenoxymethylpenicillin (abbocillin), EEM if allergic to PCN

Question 23

Skin disease by flesh eating bacteria: S pyogenes or S aureus, usually extremities, trunk, perineum, post op sites, LETHAL if not treated. redness and edema with large bullae (bubble) and black skin, gangrene or underlying thrombosis, can cause ophthalmic artery occlusion, lagophthalmos, disfigurement

1. Condition
2. Treatment

Answer 23

1. Necrotizing Fasciitis

2. IV benzylpenicillin and debridement of necrotic tissue/ reconstructive sx

Question 24

Acute viral infection by human specific double-stranded DNA poxvirus, typically affects healthy children between 2 and 4 y/o -MCV1, also immunocompromised adults or STD - MCV2, chinstrap in HIV, transmission with contact with infected people, most prevalent in tropics, painless, can be itchy

1. name
2. histology - structures and cellular inclusions affect
3. What if lesions on lid margin shed the virus
4. Management
5. tx for immunocompromised patients
6. Differential Dx

Answer 24

1. Molluscum Contagiosum
2. Henderson patterson bodies - large round structures with virons and eosinophil/basophils- waxy, smooth domes, cellular inclusions - produce hyperplasia that causes epithelium to slough off and form central cavity
3. secondary ipsilateral chronic follicular conjunctivitis
4. self limited, resolves in 6-18 months, but tx recommended for itching and cosmetics and autoinocculation prevention - Cauterize, shave, laser, cryo
5. topical autoimmunomodulatory agents like Aldara or Zyclara - Imiquimod - off label, or Zymaderm, tea tree oil, apple cider vinegar?
6. Verruca vulgaris, squamous cell carcinoma, basal cell carcinoma

Question 25

Virus called varicela - chickenpox in children and shingles - culebrilla in adults, caused by Varicella zoster virus, infecting the dorsal root ganglion - first Div of trigeminal nerve - unilateral. Typically affects elderly. If it affects the nasociliary branch of trigemnial nerve - there is a vesicle at the tip of the nose - Hutchinson sign - 60% risk of ocular involvement, 40% risk without hutchinson 1. Name 2. How to diagnose 3. signs 4. rash progression 5. Cause of chronic pain 6. DDX 7. eye parts involved 8. systemic evaluation 9. General Tx 10. pharm for adults under 72 hrs of onset 11. Pharm for adults over 60, not immuno, not DM, no TB 12. Anti ulcer therapy for HZV 13. children tx 14. what frequently appears during acute phase 15. tx that interferes with pain signals in post herpetic neuralgia, but not used around the eyes 16. how is it spread, who is susceptible, how is it prevented 17. follow up

Answer 25

1. Herpes Zoster Ophthalmicus 2. tingling sensation of the scalp, prodromal itch around the eye, Hx of shingles 3. unilateral lesions up to midline, lymphadenopathy, erythema spread from forehead to eyelid, fluid filled maculopapular rash with erythematous base, edema can spread to other side 4. Vesicles, pustular lesions, crusted lesions, resolution 5. Post-Herpetic Neuralgia 6. HSV, bacteria, dermatosis, neoplasm 7. cornea, retina, uvea 8. under 40 - rule out immunocomp, 40-60- refer if immuno, over 60 - steroid work up - immuno pts do not receive steroids 9. Oral Acyclovir, Vitamin B12, analgesic - narco or non narco, topical ABs prophylaxis, 10. acyclovir 800 mg, famciclovir 500 mg, Valcyclovir 1000 mg 11. Prednisolone 60 mg 3 days, 40 mg 3 days, 20 mg 4 daysto minimize post herpetic neuralgia, AB for lesions 12. Antiacid, H2 blocker - Cimetidine for ulcer and neuralgia 13. same as adults, unless systemic spread 14. depression - antidepressant may be used 15. Capsaicin 16. inhalation, children/adults who havent had chickenpox, Zostavax vaccine 17. every 1-7 days if occular involvement, 1-2 weeks if not. resolves after 3-6 months

Question 26

most common virus in humans, Type 1 is oral, Type 2 is genital, causes secondary blepharoconjunctivitis, transmitted by saliva or contact with vesicles, incubation takes 1 week. 25% have recurrence, must be differentiated from impetigo, vesicles along the base of the eyelashes, pinhead size, with erythematous base, generally resolves without scarring1. Disease2. Symptom3. what needs ruled out4. form without vesicles, erosion at gray line, area tender and swollen, more prevalent5. Treatment for eyelids only6. Treatment for skin lesion

Answer 26

1. Herpes Simplex Virus2. Herpes Simplex Blepharitis3. Genital history of HSV to rule out Type 24. Erosive Ulcerative form5. topical antivirals can be used to prevent cornea infection, Trifluridine or Ganciclovir, F/U 3-5 days6. warm saline solution compresses, aluminum sulfate to dry, cetaphil to clean, calamine for itch

Question 27

Crab louse found mostly in pubic hair but can infest facial hair, transferred to eye by sexual contact or bedding, towels, translucent eggs, dark colored lids due to fecal matting of lids. 1. organism responsible2. How to treat scalp and body, remove crabs, lashes with eggs, other tx

Answer 27

1. Phthiriasis Palpebrarum2. 1% lindane gamma benzene hexachloride "Rid" pediculicide OTC, wash bedding, check family, epilate lashes with eggs, physostigmine, yellow murcuric oxide, fluorescein.

Question 28

crab louse found mostly in pubic hair but can infest facial hair, transferred to eye by sexual contact or bedding, towels, translucent eggs, dark colored lids due to fecal matting of lids. 1. organism responsible2. How to treat scalp and body

Answer 28

1. Phthiriasis Palpebrarum2. 1% lindane gamma benzene hexachloride3.

Question 29

Anterior Chronic Inflammation of lid margin as part of a dermatologic condition that extends into scalp, face, eyebrow, appears as greasy scales above eyelid and at eyebrow area, runs a long course, common presentation as dandruff, frequently associated with seborrheic MGD - no expression. 1. name2. management- for dandruff, MGD, infection, Associated KCS

Answer 29

1. Seborrheic Blepharitis - Chronic Anterior Blepharitis 2. baby shampoo, lid scrubs, consider superinfection - Bacitracin or Erythromycin, artificial tears,

Question 30

Anterior Chronic Inflammation as part of a dermatologic condition that extends into scalp, face, eyebrow, appears as greasy scales above eyelid and at eyebrow area, runs a long course, common presentation as dandruff, frequently associated with seborrheic MGD - no expression. 1. name2. management- for dandruff, MGD, infection, Associated KCS

Answer 30

1. Seborrheic Blepharitis - Chronic Anterior Blepharitis 2. baby shampoo, lid scrubs, consider superinfection - Bacitracin or Erythromycin, artificial tears,

Question 31

Cause of chronic posterior Blepharitis, MG hyper secretion or stagnation, foamy lid margins, capping, clear fluid, oily tear layer, chalazion, burning, pain, FB sensation.1. Name2. Mild to moderate treatment3. Moderate to severe or resistant

Answer 31

1. MGD2. Hot compress, massage and expression, Azasite (AB that reduces NF-kB, suppresses inflammatory mediators, reduces MMP-9)3. Doxycycline 50 mg BID 2-4 weeks, then taper to 20 mg for 3 months

Question 32

Cause of chronic posterior Blepharitis, MG hyper secretion or stagnation, foamy lid margins, capping, clear fluid, oily tear layer, chalazion, burning, pain, FB sensation.1. Name2. Mild to moderate treatment

Answer 32

1. MGD2. Hot compress, massage and expression, Azasite AB3.

Question 33

Bacteria proliferation causing inflammation and obstruction of meibomian glands. Herpermic lid margins with capping, creamy white secretions, DES, SPK, rosacea, chalazia, burning, tearing.1. Name2. Treatment for mild to moderate3. Treatment for moderate to severe/resistant

Answer 33

1. Meibomianitis2. Hot soaks, massage/expression, bacitracin/erythromyicin, Azasite3. Doxycycline for 4 weeks then 3 months

Question 34

Lipogranulomatous inflamation of a meibomian gland, may follow internal hordeolum, paplable, well defined subcutations nodule in eyelid, could be associated with chronic blepharitis, or unresolved internal hordeolum. PAINLESS. 1. Name2. Initial treatment3. if unresolved, rule of thumb for excision, who should not recieve the tx4. what to rule out if resistant to tx

Answer 34

1. Chalazion2. hot soaks/massage3. Triamcinolone injection - rule of thumb - greater than 6mm or older than 6 months and unresponsive = excision, do not administer triamcinolone in dark complexion patients4. Rule out sebaceous cell carcinoma

Question 35

Swollen eyelid due to type 1 hypersensitivity reaction - IgE mediated, exposure to allergens, insect bites, with angioedema and urticaria - erythema and pruritis, can also be caused by stress, idopathic (lupic or hashimoto sign, if unable to find cause, send to Dr,) psychogenic

Answer 35

Acute Allergic Blepharoedema

Question 36

Sudden onset of bilateral pitting periorbital edema, usually by insect bites or drugs, Type 1 hypersensitivity reaction. 1. Name2. Treatment

Answer 36

1. Acute Allergic Edema2. systemic antihistamines like diphenhydramine or loratadine

Question 37

Inflammatory response that usually follows exposure to a medication or preservative, cosmetics, metals. Individual is sensitized on first exposure and develops an immune reaction on further exposure. Mediated by delayed type 4 hypersensitivity response, dry red itchy scales, chemosis, papillary reaction, tightness. 1. Name2. treatment - prevent, if keratitis is present, inflammation, allergies

Answer 37

1. Contact Dermatitis2. Stop exposure to allergen, non preservative drops for keratitis, cold compress, topical steroids - hydrocortisone or betamethasone, oral antihistamine

Question 38

common skin inflammation with eczema associated with asthma and hay fever, eyelid involvement is possible with generalized dermatitis, thickening, crusting, vertical fissuring, staph blepharitis, madarosis. Common VKC in children and KCS in adults, uncommon - Keratoconus from rubbing1. Name2. Treatment

Answer 38

1. Atopic Dermatitis2. Emollients to hydrate skin, topical steroids like hydrocortisone, ABs if infected,