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A detailed discussion of various aspects of staphylococcal blepharitis is presented. These include epidemiology, pathogenesis and immunity, microbiologic characteristics, clinical signs, associated systemic diseases, differential diagnosis, and treatment.
In 28 subjects the diagnosis of an erosive-ulcerative herpes simplex blepharitis was confirmed by laboratory tests. The clinical manifestations were characterized by the presence of erosions of the intermarginal portion of the lid or the presence of skin ulcers located at the lid margin or the combination of both features, and usually by an absence of vesicular eruptions. Erosions of the intermarginal portion of the lid can readily be made visible by staining with fluorescein. The involved lid portion usually exhibits mild swelling and tenderness on palpation. Conjunctival injection usually is not pronounced adjacent to the lid lesion, the regional lymph nodes being swollen. Laboratory confirmation can be achieved readily by the indirect immunofluorescence technique. The treatment modality consists of the combination of antibiotic and virustatic ointments.
A 36-year-old man had several episodes of left angular blepharoconjunctivitis associated with upper respiratory infections, herpes labialis, or emotional stress. The clinical diagnosis had always been a blepharitis of bacterial origin. During the last attack, cytologic examination of a scraping obtained from an eyelid pustule vesicle revealed multinucleated keratinocytes, diagnostic of a herpetic infection. Virologic studies proved that herpes simplex virus type 1 was the causal agent.
PURPOSE: To describe the ophthalmic findings of patients with discoid lupus erythematosus. METHOD: We describe two women who originally were thought to have asymmetric posterior blepharitis; however, the involved eyelid also had an erythematous, scaly cutaneous lesion. RESULT: In both patients, histology and immunofluorescence studies performed on cutaneous biopsy specimens established the diagnosis of discoid lupus erythematosus. CONCLUSIONS: It is important to diagnose discoid lupus of the eyelids because misdiagnosis can delay treatment and thus lead to deformities of the eyelid margin. Misdiagnosis can also lead to a complicated full-thickness eyelid biopsy and delay the diagnosis of systemic lupus erythematosus.
We studied cell-mediated immunity to staphylococcal antigens in 116 patients with chronic blepharitis and eight normal subjects. Antibodies in tears and blood were measured. Enhanced cell-mediated immunity to Staphylococcus aureus was demonstrated in 46 of 116 patients (40%) in the absence of antibodies to teichoic acid but not among normal subjects. Symptoms of grittiness and morning stickiness were more frequent among patients without enhanced responses. Folliculitis occurred more commonly among patients with enhanced immunity. Marginal keratitis occurred equally among patients with and without enhanced systemic immunity, but patients with enhanced response more commonly required topical corticosteroid therapy. Desensitization to staphylococcal antigens could be investigated as a potential therapeutic approach in selected patients.
BACKGROUND: Blepharoconjunctivitis is the commonest manifestation of ocular rosacea. Cilia epilation proves Demodex folliculorum, considered an etiologic factor in rosacea. Complications and differential diagnosis include dry eyes, seborrheic, bacterial and allergic blepharoconjunctivitis. Treatment involves lid scrubs and mercury ointment, its duration is limited to 6 weeks under frequent control due to corneal toxicity of mercury. HISTORY AND SIGNS: 30-year-old female with complaint of red, irritated eyes for 21 years, resistant to antibiotics and antiallergics. General medical history unremarkable, mercury allergy. Acuity: R/L 20/20. Biomicroscopy: red, thickened eyelid margins, crusty debris on rarefied, partially broken lashes, conjunctival telangiectasia, low tear meniscus, further ophthalmologic examination unremarkable. DIAGNOSIS: chronic Demodex blepharoconjunctivitis. THERAPY AND OUTCOME: Conventional treatment was contraindicated due to mercury allergy. Alternative oral minocycline 100 mg daily brought no subjective nor objective relief. Combination of lid scrubs and 2% Metronidazole gel relieved symptoms and halved number of mites after 1 month, lashes grew again after 2 months. Treatment was discontinued after 6 months as Demodex folliculorum proof remained negative. No relapse occurred during 1 year. CONCLUSIONS: Topical Metronidazole 2% proved to be an effective treatment of chronic Demodex blepharoconjunctivitis in our case and thus may offer a new and save alternative to existing therapies. Neither ocular nor systemic side effects occurred. Controversial theories on the aetiology of blepharitis are discussed.
An autosomal recessive mutation had been previously X-ray-induced in the rat and named the masked rat (genotype mk/mk). This study describes the mutant's appearance, histology, and microflora. The rat's eyelids were swollen, often to the point of closure, and its face was partially covered by a brownish crust, giving the mutant a mask-like appearance. The chronic blepharitis was also accompanied by alopecia that appeared as bare patches across the mutant's back. Pasteurella pneumotropica was found in eyelids and on skin from all masked rats. The normal rat demonstrated a resistance to Pasteurella pneumotropica infection, or, conversely, the masked rat appeared to be genetically predisposed to pasteurellosis.
An immune deficiency state is proposed as the cause of a disorder affecting a father and son with chronic dermatitis, purulent blepharitis with corneal ulceration, and scarring pyodermatous alopecia of the scalp. The results of immunologic investigation revealed abnormal neutrophil function with a variable decrease in intracellular killing, decreased lymphocyte transformation, increased serum IgG and IgE, and elevated serum copper levels. These findings will be compared with previously described immune deficiency disorders.
Two cases of pyogranulomatous blepharitis (inflammation of the lid margins) in the dalmatian are described. The diagnosis was confirmed on biopsy of the lid lesions. Bacteriology performed in one case was negative. Both cases responded to treatment: one responded well to a course of systemic steroids (prednisolone 1 mg/kg at a decreasing dose over three weeks), while the other, which was negative on culture, responded to a six-week course of cephalexin (30 mg/kg twice daily). This second dog also presented with a localised lymphadenopathy; the owner had suffered a similar reaction three years previously as a result of a penetrating injury by a pyracantha thorn.
A double-masked, placebo-controlled, randomized study was done to assess the safety and clinical and quantitative microbiologic efficacy of 1% mercuric oxide (yellow) ophthalmic ointment in the treatment of eyelid infections, i.e., bacterial blepharitis. A total of 39 patients with bacterial counts and clinical signs indicative of eyelid infection were treated twice daily for 7 days. Clinical biomicroscopic examination and quantitative microbiologic cultures were done just prior to initiation of treatment and again on days 3 and 7. Statistical analysis revealed a significant improvement in the clinical signs, bacterial count, cure rate, and improvement rate for subjects taking the active medication, compared with those taking the placebo on days 3 and 7. In addition, the medication was well tolerated.
The tear levels of cholesterol of 17 patients with chronic blepharitis and 17 healthy subjects were determined by the photometric method. The mean cholesterol level of the patients was determined to be 56.1 +/- 8.9 (SEM) mg/dl. No statistically significant difference between the tear cholesterol levels of the two groups could be detected.
An international multicentre study assessed the clinical and antibacterial efficacy of a new topical ophthalmic formulation of the quinolone antimicrobial agent ciprofloxacin and compared it with that of tobramycin ophthalmic solution in patients with blepharitis and blepharoconjunctivitis. The study consisted of a randomised double-masked between-group evaluation of 464 patients, 230 of whom were treated with ciprofloxacin and 234 with tobramycin. There was qualitative and quantitative bacteriology, and clinical assessment of ocular symptoms and signs before and after a seven-day course of treatment. Bacteriological cultures demonstrated eradication or reduction of potentially pathogenic bacteria in 93.7% of eyes (ciprofloxacin) versus 88.9% of eyes (tobramycin), seven days after starting treatment. Clinically more than 80% of patients in both treatment groups were cured or improved after seven days. No statistically significant differences were observed between the two treatment groups. No serious side-effects were observed after use of either antimicrobial agent. Ciprofloxacin ophthalmic solution appears safe and effective. The spectrum of activity and clinical efficacy of this new formulation are discussed in comparison with currently used antimicrobial agents.
A fifty five-year old woman suffered from itching and scaling of the edge of her eyelid. She had long used topical corticosteroid for this condition. Direct examination of the scale by Parker KOH showed numerous fungal elements of spores and hyphae of Malassezia furfur. She was treated with oral itraconazole (100 mg daily or twice a week) for 8 weeks and was cured clinically and mycologically. The result suggests the possibility of treatment with an anti-fungal drug for seborrhoeic blepharitis or seborrhoeic dermatitis.
Poor hygienic practices exacerbate blepharitis and impede successful resolution. Contact lens management and use of cosmetics are two frequent areas where simple interventions yield good results. Symptoms may include irritation, itching, burning, tearing, photophobia, and foreign body sensation. Treatment is the same for all causes and has the goal of removing offending irritants.
Group 568 patients with chronic marginal blepharitis was investigated for the presence of Demodex folliculorum and D. brevis on palpebral margins. The parasites were found in 387 cases (68% examined population). D. folliculorum--258 (67%) and D. brevis--129 (33%).
Tetracycline administered in low doses can be effective in the long-term management of patients with meibomian keratoconjunctivitis (MKC). However, the mechanism of action does not appear to be a reduction of bacteria. Seventy-five percent of the ocular staphylococci in such patients are resistant to tetracycline. An alternative mechanism of action could be the inhibition of production of extracellular enzymes by the ocular flora. Inhibition of lipase production could result in lowered levels of toxic hydrolysis products (free fatty acids), which may exacerbate the disease process. The authors tested this hypothesis by examining the differential effect of tetracycline on growth and lipase production in a tetracycline-resistant and tetracycline-sensitive strain of Staphylococcus epidermidis and S. aureus isolated from patients with MKC and Staphylococcal blepharitis. Tetracycline caused significant decreases in the production of lipase in the sensitive and resistant strains of S. epidermidis without concominant decreases in growth. In contrast, S. aureus strains showed parallel decreases in both lipase production and inhibition of growth. The authors propose that the sensitivity of lipase production to tetracycline, in tetracycline-resistant S. epidermidis, may partially explain the clinical improvement observed in MKC patients.
The authors analyzed the long-chain fatty acids derived from the wax and sterol ester fractions of meibomian secretions from patients with chronic blepharitis and normal individuals. Meibomian secretions were partitioned into separate lipid classes by thin-layer chromatography (TLC). Wax and sterol esters were eluted and transesterified. The liberated fatty acid methyl esters (FAME) were analyzed by gas liquid chromatography. Equivalent chain lengths (ECL) were determined for the 58 peaks found. Thirty-three peaks were positively identified by standards. Peaks were quantified by area normalization. Percentage compositions were computed for each individual and tabulated by group; each fatty acid was analyzed by analysis of variance, and each clinical group was compared with normal subjects. The authors found increases in the series of monounsaturated fatty acids from patient wax/sterol esters compared with normal subjects (P less than 0.05). The authors also found differences in some members of the series of normal, straight, and branched saturated moieties. These differences between normal groups and the blepharitic groups represent a biologically significant pattern that may relate to the disease process. Discriminant analysis provided a 73% probability of correct classification into clinical groups based strictly on FAME analysis (P less than 0.05).
Chronic blepharitis has been a difficult disease to define either microbiologically or biochemically. Sterols from meibomian secretions of normal subjects and patients were analyzed, and important differences were observed. Based on analyses of these secretions, two significantly different (P less than 0.001) types of normal subjects were found, those with and those without cholesterol esters [Norm(CP) and Norm(CA), respectively]. All patients' secretions contained cholesterol esters. Evidence was obtained which suggests that oxysterols may control the ester cholesterol accumulation. Furthermore, only when cholesterol esters were present did wax and sterol esters containing unsaturated fatty acids accumulate. Over 90% of these unsaturated fatty acids were normal (unbranched); the rest were iso-fatty acids. Preliminary results also suggest that the ester fatty alcohols are much more complex than previously reported; seven alcohols were common to all samples analyzed. Additionally, highly oxygenated alcohols were detected, especially in the meibomian keratoconjunctivitis (MKC) disease group. The MKC samples also contained an alcohol (mass, M/Z 378) not present in any of the other samples analyzed. Based on analysis of variance and linear-regression models, it was determined that the long-chain (C20-28) fatty acids were more important in determining disease signs. Furthermore, in the MKC group, the ratio of unsaturated C18 fatty acids to cholesterol in the wax and sterol esters was significantly different (P less than 0.05) from the Norm(CP) group. The authors discuss the fact that rabbit meibomian secretions are stable, despite containing a very high percentage of ester sterols, and relate this to their high percentage of branched-chain fatty acids and low percentage of unsaturated fatty acids.(ABSTRACT TRUNCATED AT 250 WORDS)