1.1. Epidemiology and Clinical Relevance
Inflammatory disorders of the eyelid constitute a major class of external eye infections affecting the elderly. The eyelid, particularly the lid margin, is a common site of ocular adnexal infection in the elderly. Staphylococcal blepharitis is by far the most common lid infection encountered. As with other forms of blepharitis, staphylococcal blepharitis is a chronic condition that has periodic exacerbations, which often leads the patient to seek medical attention.
Hordeola are infections of the lid margin sebaceous glands and manifest in two clinical forms: external (stye) and internal. These two forms are differentiated by the particular group of sebaceous glands infected. An external hordeolum (stye) is an infection of the glands of Zeis, which extend along the base of the eyelash hair follicle. It is by far the most common type of hordeolum, and Staphylococcus aureus is the predominant microbial pathogen.
A lid lesion that is often confused with an internal hordeolum is a chalazion. A chalazion is a sterile granulomatous reaction to inspissated and impacted meibomian gland secretions. Meibomian gland orifices often become plugged as a result of lid margin inflammation produced by chronic blepharitis. Consequently, meibomian gland secretions build up within the gland and eventually leak out into the surrounding lid connective tissue. These lipid secretions are highly inflammatory and incite a granulo-matous inflammatory reaction, which leads to the formation of a chalazion.
From: Infectious Disease in the Aging Edited by: Thomas T. Yoshikawa and Dean C. Norman © Humana Press Inc., Totowa, NJ
1.2. Clinical Manifestations
Patients with blepharitis usually complain of bilateral eye redness, irritation, burning, and tearing. In general these symptoms constitute no more than an annoyance, but can become incapacitating during acute exacerbations. The predominant clinical findings include bilateral lid margin crusting, the accumulation of dandruff-like flakes at the base of the lashes, and lid margin hyperemia (see Fig. 1). Over time, because of the chronic nature of this condition, many patients sustain permanent structural changes to the lid margin, consisting of lid margin thickening, loss of lashes (madarosis), and misdirected lashes.
Meibomitis, which is generally considered a manifestation of blepharitis, is an associated finding in almost every case. Meibomitis specifically refers to inflammation of the meibomian glands, which supply the lipid layer of the tear film. The lipid layer of the tear film is the most superficial layer and retards tear evaporation. Inflammation of the meibomian glands disrupts the production and secretion of the tear film lipid layer and consequently, leads to rapid tear evaporation and ocular surface drying. Thus, in addition to the symptoms noted above, patients will complain of a sandy-gritty foreign body or dry eye sensation as result of ocular surface drying.
To view inflammation of the meibomian glands, it requires the magnification of the slitlamp biomicroscope; the lesion manifests as pouting and dilation of the orifices, which lie just posterior to the lashes, and inspissation of the meibomian secretions. Several of the orifices will also display complete occlusion as a result of plugging by congealed meibomian secretions.
Because of the association with the lash follicle, an external hordeolum, or stye, manifests primarily at the base of an eyelash, with redness, swelling, and microabscess formation being the predominant clinical features.
Internal hordeola arise as a result of infections within the meibomian glands. Staphylococcus aureus is the major microbial pathogen in this condition as well. Internal hordeola typically manifest as red swollen large discrete nodules in the lid a clear distance away from the lid margin. Additionally, these lesions are generally more tender than styes and point toward the conjunctival surface instead of the external lid surface. The overlying conjunctiva will show marked hyperemia.
Chalazia clinically manifest as large discrete nontender nodules within the lid a fixed distance away from the lid margin (see Fig. 2). Although these lesions look similar to internal hordeola clinically , there are some important differentiating features. Whereas an internal hordeolum represents an acute infectious process, a chalazion is a chronic noninfectious process. Therefore, internal hordeola develop over a much shorter time period (days versus weeks), manifest signs of acute inflammation such as redness, swelling, and tenderness, and require systemic antibiotic therapy for effective treatment. In contrast, chalazia develop over a period of weeks to months, are nontender, have minimal to no associated inflammatory signs, and are effectively treated with lid hygiene and warm compresses in most instances.
The diagnosis of all of these infectious processess of the lid is made clinically; consequently, no laboratory or radiological tests exist to aid in the diagnosis of these conditions.
Treatment of blepharitis consists of lid hygiene and a short course of antistaphylococcal antibiotic therapy. Lid hygiene is performed with dilute baby sham poo dissolved in warm water (one or two drops of baby shampoo in a bottle cap full of warm water) and a cotton tip applicator or wash cloth two to three times daily. Commercially prepared eyelid cleansing kits are available over the counter but are generally more expensive. Lid hygienic therapy does not completely eradicate this disease process but simply brings it under control such that patients are symptom free. Consequently, patients must undergo prolonged courses of lid hygiene, usually over several months, and require lifetime maintenance therapy thereafter for disease control. Two to 3 wk courses of topical antistaphylococcal antibiotic therapy should be reserved for acute flareups or severe, previously untreated disease and should be combined with lid hygiene. Bacitracin or erythromycin ophthalmic ointments are the agents of choice. Systemic tetracycline has been shown to be quite effective in bringing advanced cases of meibomitis under control.
External hordeola, or styes, often sharply localize and rupture spontaneously within a matter of days after forming and thus, warm compresses four to six times a day more than suffices for treating this condition. Resolution can be hastened if the localizing lesion is decompressed with a fine sterile needle. Antibiotic therapy is of questionable value for a single lesion and is often not indicated. In the case of recurrent or multiple styes, topical antistaphyloccocal antibiotic therapy in the form of bacitracin or erythro-mycin ophthalmic ointment is warranted along with lid hygiene, and depending on the severity, systemic antistaphylococcal antibiotics may be required.
Unlike styes, internal hordeola usually do not rupture and drain spontaneously, and require warm compresses in conjunction with systemic antistaphyloccocal antibiotics. If the lesions do not respond to this regimen, incision and drainage is indicated, and the patient should be referred to an ophthalmologist.
Lid hygiene is the key to prevention for each of the lid infectious processes. Patients who present with recurrent lid infections should be advised to incorporate twice daily lid cleansing into their daily personal hygiene regimen.
2. LACRIMAL SYSTEM INFECTIONS 2.1. Epidemiology and Clinical Relevance
Lacrimal system infections commonly affecting the elderly predominantly involve the lacrimal outflow system. The lacrimal outflow system is composed of the puncta, which are present on the medial aspect of the upper and lower lid margins; the upper and lower canaliculi, the nasolacrimal sac, and the nasolacrimal duct (see Fig. 3). Infections of the lacrimal gland (dacryoadenitis) are uncommon and will not be discussed here.
A number of organisms have been found to infect the canaliculi including bacteria (i.e., Actinomyces israelii, Propionibacterium spp., Nocardia, and Bacteroides), viruses (i.e., herpes simplex and varicella-zoster), and fungi (i.e., Candida and Aspergillus spp.).
Despite this seeming variety of potential infectious agents, A. israelii causes the overwhelming majority of canalicular infections.
Dacryocystitis refers to an infection of the nasolacrimal sac that often develops as a result of blockage of the nasolacrimal duct. Nasolacrimal duct obstruction causes tear stasis, which leads to ascending bacterial colonization and infection of the nasolacrimal system from the nasopharynx (1). The cause of acquired lacrimal drainage obstruction may be primary or secondary. Primary acquired nasolacrimal duct obstruction results from inflammation of unknown cause that eventually leads to occlusive fibro-sis. Secondary acquired lacrimal drainage obstruction may arise from a wide variety of infectious, inflammatory, neoplastic, traumatic, or mechanical causes. In the elderly, the primary acquired form predominates.
Canaliculitis clinically manifests with the patient complaining of excessive tearing (epiphora). In addition to the symptom of tearing, the patient will exhibit conjunctival injection, particulary in the nasal area, along with punctal dilation and hyperemia. Digital pressure applied to the medial canthal area will often lead to punctal expression of a yellow-green exudate or yellowish "granules," which is highly characteristic of A. israelii infections.
Dacryocystitis may manifest as either an acute or chronic infectious process. The acute infectious process presents with localized pain, swelling, and erythema in the medial canthal area, representing an inflamed and distended nasolacrimal sac. Digital pressure applied to the skin overlying the nasolacrimal sac usually results in the expression of purulent material from the eyelid puncta. Patients will often complain of excessive tearing as well as eye redness and purulent discharge. The most common microbial pathogens in adults are staphylococcal and streptococcal species.
Chronic dacryocystitis typically manifests subtly with patients complaining of chronic or recurrent bouts of excessive tearing. The skin over the lacrimal sac usually appears normal, but digital pressure applied to the medial canthal area often results in the expression of purulent material from the puncta. Additionally, patients may also report intermittent episodes of conjunctivitis in the eye ipsilateral to the chronic dacryocystitis. The conjunctivitis results from the reflux of the bacterial pathogens infecting the nasolacrimal sac into the eye through the puncta. Because of the low-grade activity of this disease process, many patients tolerate the symptoms for an extended period of time before seeking medical attention.
2.3. Diagnostic Tests
In cases of canaliculitis, diagnostic confirmation of Actinomyces can be obtained by Gram-staining the expressed material, which will demonstrate delicate Gram-positive branching filaments.
The diagnosis of dacryocystitis is generally made clinically, but culturing any expressed discharge can be helpful in precisely targeting antibiotic therapy to the causative organism.
Treatment of canaliculitis consists of mechanical expression of the exudative or granular material from the canaliculi combined with probing and irrigation of the nasolacrimal system with either a 10% sulfacetamide solution or a penicillin G (100,000 units/mL) eyedrop solution. Patients should be referred to an ophthalmologist for definitive therapy of this condition.
Systemic antibotic therapy is required in all cases of dacryocystitis and empiric therapy with an antibiotic with good Gram-positive coverage, such as oral dicloxacillin or cephalexin is usually started while culture specimens are being processed.
Although systemic antibiotics can be curative in acute disease, they are of little benefit in chronic disease. These patients have total nasolacrimal duct obstruction and require surgical decompression for disease eradication. Irrigating the nasolacrimal sac through the puncta with an antibiotic solution, similar to that used to treat canaliculitis, is a good temporizing measure worth instituting in those patients who cannot undergo immediate surgical drainage. Definitive therapy ultimately rests with the ophthalmologist.
Currently, there are no known preventive measures that patients can take to avert either of these condition.
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