1. If your patient has a persistent unilateral conjunctivitis, consider molluscum contagiosum
Molluscum contagiosum presents as an elevated skin-coloured lesion. Normally the lesions on the skin are asymptomatic but on the eyelid margin the lesion sheds viral particles continuously onto the conjunctiva causing irritation and redness – look carefully between and below the lashes for the viral lesion. This doesn’t respond to chloramphenicol.
Contrary to management at all other skin sites, mulloscum lesions near the lid margin need to be removed in order to settle the conjunctival inflammation. This can be done by curetting the lesion and cauterising the base.
2. If your patient has unilateral blepharitis, or a chalazion which has not resolved after three months, consider sebaceous cell carcinoma
Beware of sebaceous cell carcinoma, which originates from the meibomian glands and can rapidly spread into the orbit, lymph nodes and metastasise.
This commonly looks like blepharitis but is unilateral and unresponsive to treatment, compared to blepharitis which is usually bilateral. A lump may only be visible when the lid is everted. It is more common in the older age group but can present in the second or third decade. If you suspect it refer to ophthalmology for a biopsy.
3. Loss of eyelashes should raise your suspicion of skin cancer
Basal cell carcinomas are the commonest type of skin cancer found on the eyelids, which are more often on the lower lids and in the older population. BCCs typically present as a raised firm lesion with pearly edges, telangiectasia and central ulceration. However, subtle morphoeic tumours are not uncommon and can be very difficult to differentiate from normal tissue by observation.
Loss of eyelashes suggests destruction of the hair follicles by tumour, and margin can sometimes be the first sign of malignancy. A notch in the eyelid margin should also raise suspicion.
4. Chalazia do not respond to topical or systemic antibiotics unless they become infected
A chalazion is a collection of oil within a meibomian gland. The free drainage of oil onto the surface of the eye is blocked because the gland opening is inflamed or the oils are too viscous.
Although the skin over the chalazion can appear mildly pink it is not infected, just inflamed so topical and oral antibiotics can be ineffective.
Patients should be advised to use a warm compress for ten minutes followed by firm massage, running a flannel under a hot tap and then holding it over their closed eye, rewarming the flannel under the hot tap regularly. This helps to liquefy the viscous oils. They should then massage downwards if the chalazion is on the upper lid and upwards if on the lower lid. It can take many weeks for a chalazion to fully resolve.
5. Patients with a facial nerve palsy cannot close their eye completely (lagophthalmos) and are particularly at risk at night of corneal exposure
They will need frequent lubricants such as carbomer gel six times a day and a thicker ointment at night such as Lacri-Lube or VitA-POS. They should be asked to put ointment into the eye at night and then dry the eyelid skin carefully. They should then cut a 5 cm length surgical tape and hold their upper lid down with the finger of one hand and place the tape horizontally onto the upper lid first then pull the upper lid down to attach the tape to the lower lid. Vertical taping does not work.
Patients at the greatest risk of corneal infections, corneal thinning and perforation are those who have lost their corneal sensation. This occurs with damage to the first division of the trigeminal nerve usually due to tumours of the cerebelopontine angle or surgery in this area such as for acoustic neuroma. These patients should be even more vigilant with their lubricants and taping.
All patients with lagophthalmos should be referred to ophthalmology, but must start their lubricants and taping immediately.
6. Orbital cellulitis is usually a result of sinus infection, so be aware of making a diagnosis of pre-septal cellulitis in a patient with coexisting or previous sinus problems
Pre-septal cellulitis is infection limited to the skin and orbicularis muscle around the eye, so there is no threat to vision or life. It typically occurs from an infected meibomian cyst and is managed with oral antibiotics.
In contrast, orbital cellulitis can be life threatening as it can spread to the cavernous sinus and meninges. It is also sight threatening due to optic nerve compression and stretching. Orbital cellulitis therefore requires urgent admission, intravenous antibiotics, CT scan and surgical drainage of collections. It usually originates in the sinuses, easily eroding and spreading through the paper thin bone between the sinuses and orbit.
To exclude orbital cellulitis and make a diagnosis of preseptal cellulitis, you must check that:
· visual acuity is normal in each eye individually
· colour vision is normal by using a red object and comparing the colour brightness and shade seen in each eye individually
· eye movements are not restricted
· pupil reactions are normal with no relative afferent pupillary defect (swinging light test)
· there is no proptosis, by standing behind the patient and peering down over the forehead to see that the corneas appear simultaneously from behind the eyebrow
· the optic disc is not swollen.
Refer urgently for ophthalmology and ENT review if one of the six tests is abnormal. Be particularly careful in the elderly and young as the septal barrier is poorly developed and preseptal infections can easily spread posteriorly and develop into orbital cellulitis.
7. Patients with a new onset ptosis and headache require urgent neuroimaging
A posterior communicating artery aneurism can press on the third cranial nerve, causing partial or complete painful third nerve palsy with and without pupil involvement. On examination they will have a ptosis, double vision when the eyelid is elevated with a ‘down and out’ eye, and a large or normal-sized pupil (complete or incomplete palsy respectively). Urgent imaging can allow coiling, clipping or embolisation of the aneurysm before life threatening rupture.
8. Smoking dramatically increases the severity of thyroid eye disease
Thyroid eye disease causes eyelid retraction, dry eyes, periocular soft tissue swelling and ache, double vision from swollen muscles, proptosis and, most severely, can lead to visual loss from optic nerve compression or corneal exposure. It can be present without thyroid dysfunction or positive thyroid autoantibodies. Stopping or reducing smoking, eye lubrication and selenium supplements (200 μg/day) can reduce the severity of symptoms.
9. Older patients with a gritty eye or corneal abrasion may have an entropion
An entropion is the turning in of the eyelid, most commonly due to lid laxity which develops with age. This causes the lashes to sit against the cornea, scratching with each blink. The entropion can be intermittent and not visible on initial examination, but can usually be triggered by asking the patient to squeeze their eyes tightly closed. Simple management methods to use whilst waiting for ophthalmology review are frequent lubrication, taping the lower lid skin down to the cheek and pulling the lower lid down to roll the lid out frequently.
10. Patients who complain of a persistent watery eye with no obvious cause should have lid hygiene advice and blepharitis treatment initiated first with ocular lubricants prior to referral
GPs should examine the eye to exclude any irritation e.g. ingrowing lashes, molluscum or sub-tarsal foreign body. If these have been excluded and the eye is white, patients can be advised that the watering is not damaging the eye and is more of a nuisance.
The first-line treatment for all patients is lid hygiene and ocular lubricants. This reduces reflex tearing from irritation of the eyelid on the eye.
Advise patients to dip a cotton bud into diluted baby shampoo and clean along all four eyelid margins at the base of the lashes morning and night and use carbomer gel qds.
If there is no benefit from this after 4-6 weeks and the watering is affecting their vision or daily living, patients should be referred to an ophthalmologist to examine the tear drainage system. If tearing settles with lid hygiene and lubricants, this should be continued long term without the need for a referral.
Miss Claire Daniel is a consultant ophthalmic surgeon at Moorfields Eye Hospital, London.
Dr Hannah Timlin is a specialist registrar and medical education fellow in ophthalmology.
