Eyelid disorders: Clinical sciences

Eyelid disorders can occur from inflammation, infections, or structural problems of the eyelids. While most eyelid disorders are non-emergent, you must quickly assess for orbital cellulitis which is a vision-threatening emergency. On the other hand, non-emergent eyelid disorders that do not threaten vision include preseptal cellulitis, blepharitis, hordeolum, chalazion, xanthelasma palpebrarum, blepharospasm, and ptosis.

Now, if a patient presents with a chief concern suggesting an eyelid disorder, first obtain a focused history and physical exam. Your patient might report redness, swelling, and pain of the eyelid. On physical exam, you might find corresponding findings including erythema, edema, and tenderness to palpation. If you see these, you’re dealing with an eyelid disorder.

Your next step is to assess for orbital cellulitis, or postseptal orbital cellulitis. In this case, history reveals fever, a painful swollen eyelid, a bulging eye, and blurry vision. The patient might also report a preceding sinusitis or upper respiratory infection. Physical exam reveals an elevated temperature, tenderness of the periorbital region, eyelid edema, violaceous discoloration, decreased visual acuity, and possibly proptosis of the eye.

With these findings, suspect orbital cellulitis and obtain labs, including a CBC, and cultures of both the blood and nasal passage or periorbital discharge cultures. Also, order imaging of the sinuses and orbits, either CT or MRI, to look for infection in the post septal region. Labs will reveal an elevated white blood cell count, while cultures might be positive. Imaging may show sinusitis, intracranial extension of the infection, or a retro-orbital abscess.

With these findings, diagnose orbital cellulitis and start IV antibiotics to cover the most common causative pathogens including Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae b. You’ll need to consult the surgical team if there’s evidence of an abscess, intracranial extension of the infection, worsening visual acuity, pupillary changes, or failure to respond to antibiotics.

Here's a clinical pearl! Patients with orbital cellulitis generally respond quickly and completely to antibiotic therapy. However, serious complications can occur, such as intracranial extension, cavernous sinus thrombosis, vision loss, and even death.

Alright, if there are no signs of orbital cellulitis, assess for non-emergent eyelid disorders. First up is preseptal cellulitis, also known as periorbital cellulitis. These patients usually report eyelid redness, swelling, and ocular pain. They might also report a fever and preceding upper respiratory infection or trauma.

Physical exam reveals eyelid erythema and edema, tenderness to palpation over the eyelid, and possibly elevated temperature. With these findings, diagnose preseptal cellulitis and prescribe oral antibiotics to cover for the most common causative pathogens including Staphylococcus Aureus, Streptococcus pneumoniae, and Streptococcus pyogenes.

Here are some clinical pearls to keep in mind! Both preseptal cellulitis and orbital cellulitis present similarly with eyelid erythema and swelling. However, preseptal cellulitis rarely leads to serious complications because the infection is limited to the eyelids and surrounding soft tissues anterior to the orbital septum. On the other hand, with orbital cellulitis, the infection extends to the orbit itself and the surrounding fat, nerves, and ocular muscles.

That being said, preseptal cellulitis usually responds rapidly and completely to antibiotics. However, if there is no improvement within 48 hours, hospitalize your patient and manage with IV antibiotics, a CT scan of the orbits, and possibly surgery for incision and drainage.

Okay, let’s talk about blepharitis. Patients may report redness and flaking of eyelids, scaly crusting along eyelashes, and a gritty sensation when blinking. Physical exam might reveal erythema of the eyelids, crusting of the lids and lashes, along with conjunctival injection. With these findings, diagnose blepharitis.

Recommend supportive care with good eyelid hygiene; which consists of warm, wet compress application and cleaning the eyelid with diluted baby shampoo. Next, recommend debridement of scales and debris with a moistened swab, and avoidance of underlying triggers, such as eye makeup. You might need to prescribe medical therapy like topical antibiotics to eradicate bacteria from the lid margin and topical steroids to reduce ocular inflammation.

Here’s a clinical pearl! Blepharitis can be associated with inflammatory skin conditions such as seborrheic dermatitis and rosacea.

Moving on to hordeolum, more commonly referred to as a stye. These patients report painful swelling of the eyelid, often at or near the lash line. There might be a history of blepharitis or rosacea, which are common precedents to hordeolum formation. Physical exam reveals eyelid erythema and edema with a tender pustule. With these findings, diagnose hordeolum.