INFECTIONS & INFLAMMATIONS OF THE LIDS

HORDEOLUM

Hordeolum is infection of the glands of the eyelid. When the meibomian glands are involved, a large swelling occurs called internal hordeolum (Figure 4-1). The smaller and more superficial external hordeolum (sty) is an infection of Zeis's or Moll's glands.

Pain, redness, and swelling are the principal symptoms. The intensity of the pain is a function of the amount of lid swelling. An internal hordeolum may point to the skin or to the conjunctival surface. An external hordeolum always points to the skin.

Most hordeola are caused by staphylococcal infections, usually Staphylococcus aureus. Culture is seldom required. Treatment consists of warm compresses three or four times a day for 10-15 minutes. If the process does not begin to resolve within 48 hours, incision and drainage of the purulent material is indicated. A vertical incision should be made on the conjunctival surface to avoid cutting across the meibomian glands. The incision should not be squeezed to express residual pus. If the hordeolum is pointing externally, a horizontal incision should be made on the skin to minimize scar formation.

Antibiotic ointment applied to the conjunctival sac every 3 hours is beneficial. Systemic antibiotics are indicated if cellulitis develops.

CHALAZION

A chalazion (Figure 4-2) is an idiopathic sterile chronic granulomatous inflammation of a meibomian gland, usually characterized by painless localized swelling that develops over a period of weeks. It may begin with mild inflammation and tenderness resembling hordeolum-differentiated from hordeolum by the absence of acute inflammatory signs. Most chalazia point toward the conjunctival surface, which may be slightly reddened or elevated. If sufficiently large, a chalazion may press on the eyeball and cause astigmatism. If large enough to distort vision or to be a cosmetic blemish, excision is indicated.

Laboratory study is seldom indicated, but on histologic examination there is proliferation of the endothelium of the acinus and a granulomatous inflammatory response that includes Langerhans-type gland cells. Biopsy is indicated for recurrent chalazion, since meibomian gland carcinoma may mimic the appearance of chalazion.

Surgical excision is performed via a vertical incision into the tarsal gland from the conjunctival surface followed by careful curettement of the gelatinous material and glandular epithelium. Intralesional steroid injections alone may be useful for small lesions, and in combination with surgery in difficult cases.

ANTERIOR BLEPHARITIS

Anterior blepharitis is a common chronic bilateral inflammation of the lid margins. There are two main types: staphylococcal and seborrheic. Staphylococcal blepharitis may be due to infection with Staphylococcus aureus, in which case it is often ulcerative, or Staphylococcus epidermidis or coagulase-negative staphylococci. Seborrheic blepharitis (nonulcerative) is usually associated with the presence of Pityrosporum ovale, although this organism has not been shown to be causative. Often, both types are present (mixed infection). Seborrhea of the scalp, brows, and ears is frequently associated with seborrheic blepharitis.

The chief symptoms are irritation, burning, and itching of the lid margins. The eyes are "red-rimmed." Many scales or "granulations" can be seen clinging to the lashes of both the upper and lower lids. In the staphylococcal type, the scales are dry, the lids are red, tiny ulcerated areas are found along the lid margins, and the lashes tend to fall out. In the seborrheic type, the scales are greasy, ulceration does not occur, and the lid margins are less red. In the more common mixed type, both dry and greasy scales are present and the lid margins are red and may be ulcerated. S aureus and P ovale can be seen together or singly in stained material scraped from the lid margins.

Staphylococcal blepharitis may be complicated by hordeola, chalazia, epithelial keratitis of the lower third of the cornea, and marginal corneal infiltrates (see Chapter 6). Both forms of anterior blepharitis predispose to recurrent conjunctivitis.

The scalp, eyebrows, and lid margins must be kept clean, particularly in the seborrheic type of blepharitis, by means of soap and water shampoo. Scales must be removed from the lid margins daily with a damp cotton applicator and baby shampoo.

Staphylococcal blepharitis is treated with antistaphylococcal antibiotic or sulfonamide eye ointment applied on a cotton applicator once daily to the lid margins.

The seborrheic and staphylococcal types usually become mixed and may run a chronic course over a period of months or years if not treated adequately; associated staphylococcal conjunctivitis or keratitis usually disappears promptly following local antistaphylococcal medication.

POSTERIOR BLEPHARITIS

Posterior blepharitis is inflammation of the eyelids secondary to dysfunction of the meibomian glands. Like anterior blepharitis, it is a bilateral, chronic condition. Anterior and posterior blepharitis may coexist. Seborrheic dermatitis is commonly associated with meibomian gland dysfunction. Colonization or frank infection with strains of staphylococci is frequently associated with meibomian gland disease and may represent one reason for the disturbance of meibomian gland function. Bacterial lipases may cause inflammation of the meibomian glands and conjunctiva and disruption of the tear film.

Posterior blepharitis is manifested by a broad spectrum of symptoms involving the lids, tears, conjunctiva, and cornea. Meibomian gland changes include inflammation of the meibomian orifices (meibomianitis), plugging of the orifices with inspissated secretions, dilatation of the meibomian glands in the tarsal plates, and production of abnormal soft, cheesy secretion upon pressure over the glands. Hordeola and chalazia may also occur. The lid margin shows hyperemia and telangiectasia. It also becomes rounded and rolled inward as a result of scarring of the tarsal conjunctiva, causing an abnormal relationship between the precorneal tear film and the meibomian gland orifices. The tears may be frothy or abnormally greasy. Hypersensitivity to staphylococci may produce epithelial keratitis. The cornea may also develop peripheral vascularization and thinning, particularly inferiorly, sometimes with frank marginal infiltrates. The gross changes of posterior blepharitis are identical to the ocular findings in acne rosacea (see Chapter 15).

Treatment of posterior blepharitis is determined by the associated conjunctival and corneal changes. Frank inflammation of these structures calls for active treatment, including long-term low-dose systemic antibiotic therapy-usually with tetracycline (250 mg twice daily) or erythromycin (250 mg three times daily), but guided by results of bacterial cultures from the lid margins-and (preferably short-term) treatment with weak topical steroids, eg, prednisolone, 0.125% twice daily. Topical therapy with antibiotics or tear substitutes is usually unnecessary and may lead to further disruption of the tear film or toxic reactions to their preservatives.

Periodic meibomian gland expression may be helpful, particularly in patients with mild disease that does not warrant long-term therapy with oral antibiotics or topical steroids. Hordeola and chalazia should be treated appropriately.

10.1036/1535-8860.ch4

Customer Privacy Policy Copyright ©2002-2003 The McGraw-Hill Companies. All rights reserved. Any use is subject to the Terms of Use and Notice. Additional credits and copyright information. For further information about this site contact tech_support@accessmedicine.com. Last modified: October 15, 2002 .