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Goals for Today

Preseptal Cellulitis Orbital Cellulitis Impetigo Staph Bleph Seborrheic Bleph Meibomitis. Hypersensitivity Rxn Phlyctenules Marginal Corneal Infiltrates Angular Bleph. Goals for Today. Dear Dr. Golden Eyes:

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Goals for Today

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  1. Preseptal Cellulitis Orbital Cellulitis Impetigo Staph Bleph Seborrheic Bleph Meibomitis Hypersensitivity Rxn Phlyctenules Marginal Corneal Infiltrates Angular Bleph Goals for Today

  2. Dear Dr. Golden Eyes: • I hope you receive my text message, since I am camping up here in the Sierra Mountains. Seven days ago I developed a painful lump in my right upper eyelid. I went to see my family doctor and he said that I had some kind of “hordelala” caused by “staff” infection. He instructed me to place a hot Russet potato on my eye. Right! Well, I didn’t do the treatment. Not gonna. It is now so red and swollen. It is painful just to touch it. I feel like it is burning up.

  3. What do I have doc? • What treatment can I do while I am up here in the mountains? • Would antibiotics help? If so, can you parachute it down to me? • Can this condition that I have get worse if left untreated? If yes, what can it lead to? • Signed: • Swollen

  4. XII. PRESEPTAL CELLULITIS • A. Background • 1. Inflammation of lid structures ANTERIOR to the orbital septum (anterior to orbital rim)

  5. 2. Caused by: • a. Facial infection: sinusitis, dental infection, soft tissue infection (H. flu in kids, Staph. in adults) • b. Blunt or penetrating trauma to lids (Strep.) • c. Eyelid infections (Staph.) • 1) Internal hordeola: 30% chance • 2) Acute staphylococcal blepharitis • d. Sinusitis is the most common cause of preseptal cellulitis

  6. 3. Limited to preseptal area by anatomical barriers • 4. Common microbes • a. H. flu in kids (likeliest, but not every case) • b. Staph. and Strep. in adults are likeliest microbes

  7. B. Signs and Symptoms of Preseptal Cellulitis • 1. Diffuse, painful swelling of lid tissue, but no proptosis • 2. Pain and tenderness may radiate past the orbital rim • 3. Pre-auricular lymph nodes may be tender • 4. Vision usually unaffected • 5. EOM's normal in preseptal cellulitis; eye movements not painful; no diplopia

  8. 6. Associated findings: • a. Hordeolum is a focal point of increased tenderness • b. Scaling, SPK suggest staphylococcal blepharitis • c. History of trauma • d. History of other infection (sinusitis, etc.) • e. Ache in sinusitis • 1) ethmoiditis: retrobulbar ache or orbital ache • 2) frontal sinus: headache • 3) maxillary sinus: ache in cheeks or teeth

  9. C. Treatment of Preseptal Cellulitis • 1. Oral antibiotics for 10-14 days • a. If likely caused by staphylococci: • (See Oral Antibiotic specific for staph page 52) • 1) Dicloxacillin • 2) 1st generation cephalosporin: Cefadroxil, Cephalexin (Keflex), Cephradine • 3) Erythromycin

  10. 4) Amoxicillin/clavulanic acid (Augmentin) is excellent, generic available • 5) may use lower doses with kids (talk to pediatrician) • 6) Trimethoprim/sulfamethoxazole (Bactrim) • Effective against MRSA

  11. If likely caused by streptococci / H. flu: • (See Oral Antibiotic specific for staph page 53) • 1) amoxicillin + clavulanic acid (Augmentin) • 2) 2nd generation cephalosporin: • Cefaclor (Ceclor), Cefprozil (Cefzil), Cefpodoxime (Simplicef, Vantin), Loracarbef (Lorabid) • 3) 3rd generation cephalosporin: • Cefixime (Suprax) • d. Range of doses depends on patient's age and weight.

  12. Warm compresses as much as possible • 3. Prophylactic antibiotic drops and/or ointment pages 14 and 15 • 4. Follow-up • a. In 1-2 days condition should not be worsening • b. If no better in 3-4 days, get culture and sensitivity STAT and consider orbital cellulitis

  13. Orbital Cellulitis • a. Risk of permanent vision loss (optic nerve) • b. Risk of loss of life if infection gets into the cavernous sinus and meninges • c. Preseptal cellulitis can worsen into orbital cellulitis if inadequately treated

  14. Emergent referral for treatment which involves hospitalization, culture and sensitivity • (See IV Anti-biotic Table page 52)

  15. d. Causes of orbital cellulitis • 1) Sinusitis (most common cause in kids) • 2) Ethmoidal wall fracture or other trauma • 3) Dental surgery • 4) Bacterial infection elsewhere (such as preseptal cellulitis)

  16. e. Most common organisms involved in orbital cellulitis (as with preseptal cellulitis) • 1) H. influenzae is #1 in kids • 2) Strep. and Staph. in adults • f. Multiple signs in orbital cellulitis • 1) Early diagnostic sign: conjunctival hyperemia and chemosis (moderate to severe); these frequently precede proptosis and diplopia • 2) External ophthalmoplegia

  17. 3) Optic nerve edema and ischemia, with variable/mild VA loss • 4) Pain on eye movement • 5) Diplopia • 6) Lid edema, erythema, possible proptosis • 7) More often unilateral • 8) Elevated WBC count • 9) General malaise: fever, chills, vomiting (patient really feels sick)

  18. XIII. IMPETIGO • A. Background • 1. Skin infection caused by staphylococci or group A streptococci (staph. is the likeliest cause, group A strep. less common) • 2. More frequent in newborns and children than in adults • a. Worsened by poor hygiene • b. Very contagious among children • 3. Occurs in warm weather (typically summer)

  19. B. Signs and Symptoms of Impetigo • 1. Exposed areas are most affected • a. Face, arms and neck • b. May involve eyelids secondarily • 2. Pathogenesis • a. Lesion begins as a macule (flat red skin spot) • b. Develops into a vesicle or pustule • c. Lesions rupture, then ooze

  20. 3. May have regional lymphadenopathy • 4. Lesions do not scar • 5. Two types • a. Bullous: larger blistered areas with or without superficial crusts; caused by Staph. • b. Vesicular: smaller vesicles, typically with honey-colored crusts; caused by Staph. and/ or Strep.

  21. C. Treatment of Impetigo • 1. Topical therapy • a. Older, more traditional therapy • b. Lesions must be debrided to expose bacteria, otherwise topical antibiotics are ineffective • c. Regimen • 1) Soak with Burow's solution for 20 minutes, BID to QID

  22. 2) Burow's solution (aluminum sulfate, calcium acetate) available in Domeboro Powder Packets (OTC); one packet to one pint of water is 1:40, two packets give 1:20 concentration • 3) Soaking softens crust and has astringent action; skin appearance improves after soaking • 4) Follow soaking with gentle debridement of crust with a wash cloth • 5) Chlorhexidene solution to further cleanse area (Hibiclens solution, 4 or 8 oz., Rx)

  23. 6) After drying, apply topical antibiotic ointment (Polysporin or erythromycin) without covering bandage • d. CONTAGIOUS; don't share washcloth with the family • e. Newer drug: mupirocin (Bactroban) 2% ointment; used TID; effective against both Staph. and group A Strep.; by Rx only; effectively replaces all older topical antibiotics

  24. 2. Systemic therapy • a. See Oral Antibiotic Table on page 55 • b.Amoxicillin/Clavulanic Acid, Dicloxacillin, 1st generation cephalosporin, 2nd generation cephalosporin, trimethoprim/sulfamethoxazole, clindamycin, tetracycline, linezolid • c. More effective than topical therapy

  25. Staphylococcal Blepharitis • D. Staphylococcal blepharitis • 1. Background • a. Staphylococcal organisms are ubiquitous • 1) S. epidermidis frequent in blepharitis • 2) S. aureus less frequent than S. epidermidis • 3) S. saprophyticus very infrequent in blepharitis

  26. b. Staphylococci are colonized on lid margins • 1) Episodes erupt when environment changes • a) Illness (acute or chronic) • b) Medications (antibiotics and steroids) • c) Poor hygiene and nutrition

  27. 2) Staphylococcal blepharitis is usually chronic • a) Due to the ubiquitous nature of Staph. • b) Waxing and waning presentations • c) Permanent structural changes due to chronic damage by staphylococcal exotoxins • d) Sudden exacerbations, awakening with painful lids

  28. 2. Signs and Symptoms of Staphylococcal Blepharitis • a. Crusts that strongly suggest staphylococcal exotoxin activity • 1) Ulcerative (synonyms: rosettes, collarettes) • a) Round, hard, yellow • b) Firmly bound down at base of lashes • c) Ulceration underneath when crust removed

  29. 2) Fibrinous (synonyms: brittle, "impaled cornflake") • a) Represent fibrin exuded from damaged tissue • b) Scale starts at base of lash, then grows with it away from lid margins • c) Often called "squamous," though "squamous" means "scaling," which is common to both seborrheic and staphylococcal processes

  30. b. Lid characteristics in staphylococcal blepharitis • 1) Erythema • a) Diffuse redness along lid margin from acute inflammation • b) Chronic neovascularization on margin • c) Deeper permanently engorged vessels • 2) Puffy from fluid accumulation • 3) Tender to palpation • 4) Acute changes due to hypersensitivity

  31. c. Keratitis • 1) Due to pooling of exotoxins in tear lake • 2) SPK in inferior third of cornea • 3) Also due to lipases breaking lipids into surface-active free fatty acids and from poor blinking • 4) Long-term: marginal infiltrates, ulceration, pannus

  32. d. Permanent structural changes • 1) All changes due to exotoxins damaging tissue • 2) Madarosis (missing lashes) • 3) Poliosis (white lashes) • 4) Tylosis (thickening) • 5) Trichiasis (misdirected lashes)

  33. 6) Lid neovascularization • a) Glomerular fronds of vessels at margins • b) Deeper vessels causing a pink "cast" • 7) Possible excoriation at external canthi

  34. Defer… • e. Hypersensitivity reactions to staphylococcal exotoxins • 1) Phlyctenule • 2) Beefy hyperemic conjunctiva adjacent to corneal involvement • 3) Marginal corneal infiltrates

  35. Combo… • f. Staphylococcal crusting can be mixed with other presentations of blepharitis • 1) Crusting may be predominantly staphylococcal • 2) May be mixed with seborrheic types • a) Scurf • b) Foamy, greasy scales • 3) May be present simultaneously with meibomitis

  36. g. Symptoms • 1) Multiple symptoms, varying on severity of staphylococcal activity and damage to tissue • a) Foreign body sensation, grittiness • b) Stinging, burning, irritation • c) Pain • d) Tender lids • e) Possible itching • f) Frequent hordeola

  37. 2) Variable depending on time of day • a) Worse upon awakening • i) Buildup of crusts during sleep • ii) Exotoxin-caused SPK during sleep • b) Worse at end of day • i) Dry eye symptoms • ii) Increasingly poor TBUT

  38. 3. Treatment of Staphylococcal Blepharitis • a. In practical terms, "staph blepharitis" is rarely a purely microbial condition but is a combination of seborrheic (greasy) processes with microbes. Treatment begins with assessment of both the immune/ hypersensitivity process (not well understood presently) as well as the microbial process (staph, exotoxins, free fatty acids).

  39. 1. Assess the severity of the immune process by the degree of pain, tenderness, redness, and swelling (all signs of inflammation) • 2. Assess the severity of the microbial process by the amount of ulceration, crusting, permanent structural damage, and FFA activity (keratitis).

  40. Ideally… • b. With the patient in the chair, remove as much of the scaling as possible with wet or dry Q tip, tweezers, or epilating forceps (you can do it better than the patient can). Some will additionally locally treat the lids with a strong antibiotic one time only (ie, Ciloxan or another fluoroquinolone drops on a Q tip).

  41. c. Steroids • 1. Necessary with moderate to severe immune processes • 2. Necessary to reduce significant erythema • 3. Necessary to reduce pain and tenderness • 4. Useful to promote subsequent successful lid hygiene • 5. (See Antibiotic Steroid Combo Table page 58) • Pred-G, Maxitrol, Cortisporin, Blephamide, Tobradex, TobradexST, Zylet

  42. 6. NEVER use long term • 7. Beware of hoarding for later use • 8. Apply ointment or suspension on Q tip or fingertip to lid margins, BID to TID, to reduce pain and redness; use no longer than 7 days to avoid tapering and risk of rebound. Lid inflammation is very responsive to steroids, even the "weaker" ones.

  43. d. Lid hygiene • 1. Remove crusts which harbor and shield bacteria • 2. Remove extra grease which enhances bacterial growth and FFA production • 3. Soak lids first with warm washcloth • 1) Softens and loosens crusts • 2) Speeds blood supply

  44. 4. Hygiene "recipes" • 1) Varying concentrations of baby shampoo to water • 2) 50:50 on Q tip • 3) 1:10 or more dilute for washcloth, cotton ball, or cotton pad • 4) Prepared lid cleaners (Eye- Scrub, etc.)

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