Chalazion Chalazion is a chronic sterile inflammation of the eyelid resulting from a lipogranuloma of the meibomian glands that line the posterior margins
... [Show More] of theeyelids (see Fig. 29-7). It is deeper in the eyelid tissue than a hordeolum andmay result from an internal hordeolum or retained lipid granular secretions. Clinical Findings
Initially, mild erythema and slight swelling of the involved eyelid are seen. After a few days the inflammation resolves, and a slow growing, round, nonpigmented, painless (key finding) mass remains. It may persist for a long time and is a commonly acquired lid lesion seen in children (see Fig. 29-7). 727
Management
• Acute lesions are treated with hot compresses.
• Refer to an ophthalmologist for surgical incision or topical intralesional corticosteroid injections if the condition is unresolved or if the lesion causes cosmetic concerns. A chalazion can distort vision by causing astigmatism as a result of pressure on the orbit.
Complications
Recurrence is common. Fragile, vascular granulation tissue called pyogenic granuloma that enlarges and bleeds rapidly can occur if a chalazion breaks through the conjunctival surface.
Types of Conjunctivitis
Type
Incidence/Etiology
Clinical Finding s
Diagnosis
Management*
Ophthalmi a neonat orum
Neonates: Chlamydia trachomatis, Staphylococcus aureus, Neisseria gonorrhoeae, HSV (silver nitrate reaction occurs in 10% of neonates)
Erythema,
chemo sis, purule nt exudat e
with N
Culture (ELISA, PCR), Gram stain, R/O N. gonorrhoeae, chlamydia Saline irrigation to eyes until exudate gone; follow with erythromycin ointment
For N. gonorrhoeae:ceft riaxone or IM or IV
Type
Incidence/Etiology
Clinical Finding s
Diagnosis
Management*
.
gonorr hoeae; clear to mucoi d exudat e with chlamy dia For chlamydia: erythromycin or possibly azithromycin PO
For HSV: antivirals IV or PO
Bacterial
conjun ctivitis
In neonates 5 to 14 days old, preschoolers, and sexually active
teens: Haemophilus influenzae(nontypeable), Streptococcus pneumoniae, S. aureus,
N. gonorrhoeae
Erythema,
chemo sis, itching
,
burnin g, mucop urulent exudat e, matter in eyelas hes; ↑ in winter
Cultures (required in neonate); Gram stain (optional); chocolate agar (for N. gonorrhoeae) R/O pharyngitis, N. gonorrhoeae, AOM, URI,
seborrhea Neonates: Erythromycin 0.5% ophthalmic ointment
≥1 year old: Fourth- generation fluoroquinolone
For concurrent AOM: Treat accordingly for AOM
Warm soaks to eyes three times a day until clear
No sharing towels, pillows
No school until treatment begins
Chronic
bacteri al conjun ctivitis
School-age children and teens: Bacteria, viruses, C. trachomatis
Same as
above; foreign body sensati
Cultures, Gram stain; R/O dacryostenosis
, blepharitis, corneal ulcers, Depends on prior treatment, laboratory results, and differential diagnoses
Review
Type
Incidence/Etiology
Clinical Finding s
Diagnosis
Management*
(unres ponsiv e conjun ctivitis previo usly treated as bacteri al in etiolog y)
on
trachoma compliance and prior drug choices of conjunctivitis treatment
Consult with ophthalmologist
Inclusion
conjun ctivitis
Neonates 5 to 14 days old and sexually active teens: C. trachomatis
Erythema,
chemo sis, clear or mucoi d exudat e, palpeb ral follicle s
Cultures (ELISA, PCR), R/O
sexual activity Neonates: Erythromycin or azithromycin PO
Adolescents: Doxycycline, azithromycin, EES,
erythromycin base, levofloxacin PO
Viral
conjun ctivitis
Adenovirus 3, 4, 7; HSV, herpes zoster, varicella
Erythema,
chemo sis, tearing (bilater al); HSV
Cultures, R/O corneal infiltration Refer to ophthalmologist if HSV or photophobia present
Cool compresses three or four times a day
Type
Incidence/Etiology
Clinical Finding s
Diagnosis
Management*
and herpes zoster: unilate ral with photop hobia, fever; zoster: nose lesion; spring and fall
Allergic
and vernal conjun ctivitis
Atopy sufferers, seasonal
Stringy,
mucoi d exudat e, swolle n eyelids and conjun ctivae, itching (key finding
),
tearing
,
palpeb ral follicle s, headac
Eosinophils in conjunctival scrapings Naphazoline/pheni ramine, naphazoline/anta zoline ophthalmic solution (see text)
Mast cell stabilizer (see text)
Refer to allergist if needed
Type
Incidence/Etiology
Clinical Finding s
Diagnosis
Management*
he, rhinitis
*See text for dosages.
Blepharitis
Blepharitis is an acute or chronic inflammation of the eyelash follicles or meibomian sebaceous glands of the eyelids (or both). It is usually bilateral. There may be a history of contact lens wear or physical contact with another symptomatic person. It is commonly caused by contaminated makeup or contact lens solution. Poor hygiene, tear deficiency, rosacea, and seborrheic dermatitis of the scalp and face are also possible etiologic factors. The ulcerative form of blepharitis is usually caused by S. aureus. Nonulcerative blepharitis is occasionally seen in children with psoriasis, seborrhea, eczema, allergies, lice infestation, or in children with trisomy 21.
Clinical Findings
• Swelling and erythema of the eyelid margins and palpebral conjunctiva
726
• Flaky, scaly debris over eyelid margins on awakening; presence of lice
• Gritty, burning feeling in eyes
• Mild bulbar conjunctival injection
• Ulcerative form: Hard scales at the base of the lashes (if the crust is removed, ulceration is seen at the hair follicles, the lashes fall out, and an associated conjunctivitis is present)
Differential Diagnosis
Pediculosis of the eyelashes.
Management
Explain to the patient that this may be chronic or relapsing. Instructions for the patient include:
• Scrub the eyelashes and eyelids with a cotton-tipped applicator containing a weak (50%) solution of no-tears shampoo to maintain proper hygiene and debride the scales.
• Use warm compresses for 5 to 10 minutes at a time two to four times a day and wipe away lid debris.
• At times antistaphylococcal antibiotic (e.g., erythromycin 0.5% ophthalmic ointment) is used until symptoms subside and for at least 1 week thereafter. Ointment is preferable to eye drops because of increased duration of contact with the ocular tissue. Azithromycin 1% ophthalmic solution for 4 weeks may also be used (Shtein, 2014).
• Treat associated seborrhea, psoriasis, eczema, or allergies as indicated.
• Remove contact lenses and wear eyeglasses for the duration of the treatment period. Sterilize or clean lenses before reinserting.
• Purchase new eye makeup; minimize use of mascara and eyeliner.
• Use artificial tears for patients with inadequate tear pools.
Chronic staphylococcal blepharitis and meibomian keratoconjunctivitis respond to oral erythromycin. Doxycycline, tetracycline, or minocycline can be used chronically in children older than 8 years old.
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