Lids and Lashes (pt 2)

Potential Dx for “Irritation and foreign body sensation”

• Trichiasis

• Distichiasis

• Blepharitis

• Parasite infestation

Trichiasis

Misdirected eyelashes from scarring or idiopathic causes

Trichiasis clinical findings

Lashes turning backwards

Trichiasis complications

PEE → Corneal ulcerations → Scarring and conj hyperemia

Trichiasis Tx

Epilation or ablation

Trichiasis hallmark signs

Normal lashes misdirected

Compare trichiasis and eyelash ptosis

Trichiasis: Lash turns backward, can be superior or inferior

Eyelash ptosis: Lash grows downward, only superior

Distichiasis

Sebaceous meibomian glands become pilosebaceous and grow an extra row of lashes

Distichiasis clinical findings

Short/thin nonpigmented lashes emerging from meibomian glands that rotate backwards

Distichiasis complications

PEE → Corneal ulcerations → Scarring and conj hyperemia

Distichiasis Tx

Epilation or ablation

Distichiasis hallmark signs

Extra row of lashes from meibomian glands

Blepharitis

Inflammation of the eyelid margin

Blepharitis types

Anterior, posterior, angular

Anterior blepharitis

Inflammation of the anterior portion of the lids (doesn’t go past lash line)

Caused by overgrown Staph A or zeis gland overproducing oil

Anterior blepharitis clinical findings

Staph blepharitis: Scales around base of lashes and eyelid hyperemia, lashes remain individual

Seborrheic blepharitis: Greasy lid margin, lashes stick together

Anterior blepharitis complications

Tear film instability, dry eye, PEE, corneal inflammation and vascularization

External hordeolum (staph blepharitis only)

Anterior blepharitis Tx

Lid hygiene

Topical antibiotic or steroid (staph blepharitis only)

Angular blepharitis

Eczematoid inflammation of lateral or medial canthus from Staph A or Moraxella lacunata

Angular blepharitis clinical findings

Staph: Dry and scaly skin

Moraxella: Wet macerated lid with frothy discharge

Angular blepharitis complications

Conj hyperemia

Angular blepharitis Tx

Broad spectrum topical antibiotic

Doesn’t get better → Culture

Posterior blepharitis

Inflammation of meibomian glands and posterior lid margin

Usually concurrent with anterior bleph because of increase staph A growth

Posterior blepharitis clinical findings

• Meibomian capping

• Thick meibum

• Lid hyperemia

• Frothy/oily tear film

Posterior blepharitis complications

• Gland loss: Blocked and not actively expressing

• Dry eye: Glands not working

• Lid margin scarring

• Conj hyperemia

• PEE, corneal neovascularization

• Internal hordeolum: Gland infection

• Preseptal cellulitis: Infection spreading

Posterior blepharitis Tx

1st line: Lid hygiene and warm compress

• Thermal pulsation

• IPL

• Antibiotics

Which oral antibiotics do you use for posterior blepharitis and why?

Tetracycline and doxycycline

Used for their anti-inflammatory properties, low dose

Anterior blepharitis hallmark signs

Scaling at base of lashes or lashes stuck together

Angular blepharitis hallmark signs

Scaling at lateral or medial canthus

Posterior blepharitis hallmark signs

Meibomian capping

Phthiriasis palpebrarum

Parasitic infection of the lashes that occurs in children of low socioeconomic groups caused by pubic lice

Phthiriasis palpebrarum clinical signs

• Lice anchored to lashes

• Conj hyperemia

• Eggs that look like small pearls adhered to lashes

Phthiriasis palpebrarum complications

• Conjunctivitis

• Anterior bleph (staph overgrowth)

• Concurrent skin infections

Phthiriasis palpebrarum Tx

Mechanical removal of lice and vaseline

Need multiple appointments

Demodex

Parasitic infection of the lashes or lid

Common in pts with rosacea or poor hygiene

Types of demodex

Demodex folliculorum (lashes)

Demodex brevis (meibomian glands)

Demodex folliculorum clinical signs

• Cylindrical dandruff from keratin overproduction

• Thin short lashes

• Conj hyperemia

Demodex brevis clinical signs

• Meibomian capping

• Corneal scarring

• Conj hyperemia

Demodex complications

Anterior and posterior bleph → If pt is compliant with Tx and it isn’t working assume Demodex

Conjunctivitis

Demodex Tx

Tea tree oil: Long Tx because of parasite life cycle

Lotilaner ophthalmic solution: Drops that work in 6 weeks

Phthiriasis palpebrarum hallmark signs

Lice on lashes

Demodex hallmark signs

Cylindrical dandruff

Meibomian capping