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Symptoms ⬇

Mild photophobia, mild pain, localized red eye, chronic eyelid crusting, foreign body sensation or dryness. History of recurrent acute episodes, chalazia, or styes.

Signs ⬆ ⬇

(See Figure 4.18.1.)

Critical

Singular or multiple, unilateral or bilateral, peripheral corneal stromal infiltrates often with a clear space between the infiltrates and the limbus. Variable staining with fluorescein. Minimal anterior chamber inflammation. Sectoral conjunctival injection typically occurs.

Other

Blepharitis, inferior SPK, phlyctenule (a wedge-shaped, raised, vascularized sterile infiltrate near the limbus, usually in children). Peripheral scarring and corneal neovascularization. Findings often present in the contralateral eye or elsewhere in the affected eye.

4-18.1 Staphylococcal hypersensitivity.

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Differential Diagnosis ⬆ ⬇

Etiology ⬆ ⬇

Infiltrates are believed to be a cell-mediated, or delayed, type IV hypersensitivity reaction to bacterial antigens in the setting of staphylococcal blepharitis.

NOTE:

Patients with ocular rosacea (e.g., meibomian gland inflammation and telangiectasias of the eyelids) are especially susceptible to this condition.

Work Up ⬆ ⬇

Workup
  1. History: Recurrent episodes? Contact lens wearer (a risk factor for infection)?
  2. Slit lamp examination with fluorescein staining and IOP measurement.
  3. If an infectious infiltrate is suspected, then corneal scrapings for cultures and smears should be obtained. See Appendix 8, CORNEAL CULTURE PROCEDURE.

Treatment ⬆ ⬇

Mild

Warm compresses, eyelid hygiene, and an antibiotic drop q.i.d. (e.g., fluoroquinolone or trimethoprim/polymyxin B) and antibiotic ophthalmic ointment q.h.s. (e.g., bacitracin, erythromycin, bacitracin/polymyxin B). See 5.8, BLEPHARITIS/MEIBOMITIS.

Moderate to Severe

  • Treat as described for mild, but add a low-dose topical steroid (e.g., loteprednol 0.5%, fluorometholone 0.1%, fluorometholone acetate 0.1% or prednisolone acetate 0.125% q.i.d.) with an antibiotic (e.g., fluoroquinolone or trimethoprim/polymyxin B q.i.d.). A combination antibiotic/steroid can also be used q.i.d. (e.g., loteprednol 0.5%/tobramycin 0.3%, dexamethasone 0.1%/tobramycin 0.3% or dexamethasone 0.05%/tobramycin 0.3%). Steroid use without antibiotic coverage is not recommended. Maintain until the symptoms improve and then slowly taper.
  • If episodes recur despite eyelid hygiene, add systemic doxycycline (100 mg p.o. b.i.d., for 2 weeks, and then daily for 1 month, and then 50 to 100 mg daily titrated as necessary) until the ocular disease is controlled for several months. This medication has an anti-inflammatory effect on the sebaceous glands in addition to its antimicrobial action. Topical azithromycin q.h.s., erythromycin q.h.s. or cyclosporine b.i.d. may be helpful in controlling eyelid inflammation.
  • Low-dose antibiotics (e.g., bacitracin or erythromycin ointment q.h.s.) may have to be maintained indefinitely.
NOTE:

Tetracyclines such as doxycycline are contraindicated in children <8 years old, pregnant women, and breast feeding mothers. Erythromycin 200 mg p.o. one to two times per day can be used in children to decrease recurrent disease.

Follow Up ⬆

In 2 to 7 days, depending on the clinical picture. IOP is monitored while patients are taking topical steroids.