Inflammatory lesions of the eyelids

Contributed by Dr Jean Watkins, a sessional GP in Hampshire

Unilateral oedema

This child presented with swelling of the eyelids of the left eye having been bitten by a mosquito a few hours earlier.

On examination there was no inflammation of the lids, vision was unaffected, the child was afebrile and he was well in himself. It was felt that this was an allergic reaction to the insect bite. The child was prescribed an oral antihistamine and the problem quickly settled.

Unilateral swelling localised to the lids, in a fit patient, without any other physical signs, is rarely a serious problem.

Orbital cellulitis

Orbital cellulitis is potentially serious and requires urgent IV antibiotics. It is usually caused by Staphylococcus aureus, Streptococcus pneumoniae, beta-haemolytic streptococcus or Haemophilus influenzae infection from the paranasal sinuses. The patient is often febrile with swelling and inflammation of the eyelids. The eye may be painful and vision impaired. In more serious cases there may be proptosis, ptosis or ophthalmoplegia.

Failure to diagnose risks cavernous sinus thrombosis, septicaemia, meningitis, deafness or loss of vision.

Stye (hordeolum)

Styes are a common problem, usually caused by a staphylococcal infection of an eyelash follicle. It is more common in those with poor hygiene or with concurrent blepharitis. A painful swelling develops and pus forms and points at the lid margin associated with an eyelash.

If the stye discharges pus spontaneously, it usually settles and clears on its own. Treatment comprises warm compresses and topical chloramphenicol ointment. Systemic antibiotics are required only if the infection appears to be spreading. If the stye fails to drain, surgical drainage may be necessary.

Meibomian cyst (chalazion)

A meibomian cyst results from blockage of the duct by secretions of the meibomian gland. The patient may first notice a firm lump in the eyelid, which becomes obvious when the eyelid is everted. Some will resolve spontaneously but others become red, more swollen and tender. Large cysts may cause visual problems with blurred vision and astigmatism.

Warm compresses may help to clear the gland and antibiotics may be used if secondary infection occurs. Steroid injections are sometimes used to reduce inflammation. If large or unresponsive to treatment, surgical removal may be indicated.

Blepharitis

Blepharitis is an inflammatory condition affecting the eyelids. There are a number of associated conditions: rosacea, herpes simplex, herpes zoster, seborrhoeic dermatitis, allergy or Sjogren's syndrome.

Patients complain of itching, soreness and redness of the lids, crusting around the lid margins and in severe cases ulceration of the lid margin.

Treatment involves warm bathing and cleansing of the lids, clearing crusts and application of a topical antibiotic cream. Short-term corticosteroids may improve symptoms more rapidly. More severe cases may require systemic antibiotics.

Contact dermatitis

Contact dermatitis occurs in patients allergic to ingredients in eye make up, applicators or brushes, or eye drops or ointments. It may also occur in patients with allergy to nail varnish or nickel, if fingers touch the eye with painted nails or after handling metal items such as keys.

This patient developed conjunctivitis in the left eye, for which she was prescribed neomycin eye ointment. Although the conjunctivitis cleared she was troubled by inflammation, swelling and itching. She was advised to discontinue the eye ointment and a short course of topical corticosteroids improved her symptoms.

Dacrocystitis

Blockage of the naso-lacrimal duct leads to stagnation of tears and infection. Dacro-cystitis is most common in women over the age of 40 or occasionally in neonates.

Patients complain of eye watering, pain, inflammation, tenderness and swelling at the inner canthus. Secondary bacterial infection leads to a spreading cellulitis around the area. Less serious cases may be treated with hot bathing, an oral antibiotic and eye drops. Topical steroid drops may be helpful in chronic cases.

As recurrence is common, surgery is recommended to clear the duct once the acute episode is over or in chronic cases.

Apocrine hidrocystoma

Apocrine hidrocystoma develops as the result of blockage of the ducts of sweat glands. They are not uncommon and tend to form most often on the lower lid, near the lacrimal punctum.

Treatment is unnecessary unless the patient is concerned. If drained, recurrence is very likely, and surgical excision of the cyst under local anaesthesia is recommended.

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