Blepharitis is associated with staphylococcal colonization of the eyelids. Poor attention to eyelid hygiene contributes to the problem. Collarettes and accumulation of debris occur around the bases of eyelashes, secondary to inflammation or infection that involves the eyelid margins.

Patients with blepharitis usually present with nonspecific complaints of irritated, itchy eyes; eyelids stuck closed in the morning; and white discharge. An examination shows crusting around eyelashes and injection of eyelid margins, and in chronic blepharitis, poliosis (whitening) or madarosis (loss) of cilia may occur. This usually is bilateral but may be asymmetric.

Blepharitis may be associated with conjunctivitis (blepharoconjunctivitis) or with a staphylococcal hypersensitivity reaction that causes tiny corneal stromal opacities. Blepharitis is often accompanied by meibomianitis, inflammation of meibomian glands, which causes meibomian dysfunction and plugging of meibomian pores along the eyelid margins. This secondarily impairs the basal lubrication of the globe and may contribute to dry eye symptoms.

The diagnosis of blepharitis is made based on history of itchy eyes with morning crusting and examination of the eyelid margins. Unlike allergic conjunctivitis, blepharitis is not associated with significant eyelid edema after manipulation, patient history of atopy or asthma, and patient or family history of environmental allergies. Seasonal recurrences are useful in differentiating the two.

Good lid hygiene is essential for treatment of this condition. This consists of mechanical and pharmacologic therapy. Parents should be instructed to apply frequent warm compresses to cleanse the eyelids and to gently run a moist cotton
applicator along eyelid margins to dislodge crusting around eyelashes and plugs on meibomian orifices. Erythromycin or bacitracin ophthalmic ointment can be applied to the eyelid margins twice a day. Blepharitis should improve with this therapy, and children who do not respond should be referred for further management to a pediatric ophthalmologist. Blepharitis is a chronic condition, and once the acute problem has resolved, continued daily use of warm compresses to cleanse the eyelid margins helps prevent flareups.

The term hordeola refers to inflammatory or infectious blockage of pores of sebaceous glands in the eyelids. The term external hordeolum, often called by the lay term “stye,” is a blockage of Zeis glands associated with eyelash follicles. Internal hordeola, or chalazia, occur when the meibomian orifices, which line the inner aspect of the eyelid margins, become occluded. On histopathologic examination, chalazia consist of a lipogranulomatous reaction. Children with blepharitis and meibomianitis are particularly prone to developing chalazia and styes.

The history will depend on chronicity. Typically, parents will either describe an acute discrete eyelid swelling or a nodule that has been present for weeks or months, which may be accompanied by periodic purulent discharge and changes in size. On examination, styes are swollen at the edge of the eyelid, while chalazia are discrete firm nodules adjacent to the eyelid margin. There may be focal “pointing” on the tarsal conjunctival aspect of the lesion. Both styes and chalazia may be inflamed and tender. If chronic, they may be associated with overlying skin changes. Multiple chalazia and styes may occur and can be impressive in size.

As described previously, styes and chalazia are characteristic in appearance. They occur at the eyelid margin, and the swelling and inflammation are well demarcated. If these lesions are associated with diffuse or spreading eyelid warmth and inflammation or systemic symptoms, such as fever or malaise, it may indicate progression to a cellulitis (see below).

Conservative therapy, consisting of frequent warm compresses, usually is effective in eradicating chalazia and styes. Recalcitrant chalazia can be treated by an ophthalmologist with incision and drainage. Although this simple office procedure is performed under local anesthesia in adults, most children cannot tolerate the injection of local anesthetic and lid clamping that the procedure requires. Because this procedure risks perforation of the globe in unsedated children, pediatric chalazion incision and drainage necessitates a trip to the operating room under general anesthesia. Therefore, committed conservative therapy by far is the best approach. Some children are predisposed to developing chalazia, and ongoing good lid hygiene should be encouraged. Because the eye itself usually is not involved, eyedrops are not helpful unless the eye is injected. If there is associated blepharitis, one may augment the warm compresses with erythromycin or bacitracin ophthalmic ointment, but parents should understand that the warm compresses, not the medication, will eliminate the hordeola.

Diffuse eyelid erythema, warmth, and tenderness indicate progression to a preseptal cellulitis that will require systemic antibiotics.

Children with a history of sinusitis, periorbital inflammation, trauma (blunt or penetrating, including insect bites), dacryocystitis, and dental abscess are at increased risk of developing preseptal and orbital cellulitis (Rumelt & Rubin, 1996). In children, the most frequent etiology of preseptal and orbital cellulitis is ethmoid sinusitis, which is radiographically present in 96% of orbital cases and 81% of preseptal cases (Barone & Aiuto, 1997). Eyelid lesions (traumatic or related to extension of localized inflammatory processes [ie, hordeola]) are the second most common cause of preseptal and orbital cellulitis in children, followed by dacryocystitis (infection of the nasolacrimal sac).

The causative organisms involved in cellulitis may be presumptively identified based on the origin of the infection. In the absence of a history of trauma, providers should suspect organisms responsible for sinusitis, such as Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis and in children with a history of chronic sinusitis, anaerobes and Staphylococcus aureus (Barone & Aiuto, 1997). H. influenzae type B, once among the most common and aggressive organisms to cause both preseptal and orbital cellulitis through bacteremic seeding, has essentially been eliminated as a source of cellulitis as a result of vaccination (Barone & Aiuto, 1997; Donahue & Schwartz, 1998). In preseptal or orbital cellulitis related to skin infections or trauma, S. aureus and Streptococcus pyogenes are the most frequent pathogens.

Parents may give a history of recurrent sinusitis or recent respiratory infection or describe an antecedent lesion related to trauma, insect bite, chalazion, or hordeolum. Frequently, they may not recall any precipitating event.

Children with preseptal cellulitis present with eyelids that are tender, swollen, tense, warm, and red. They may exhibit some degree of malaise and be febrile. The globe itself is quiet and uninvolved with normal pupillary reflex. Extraocular movements are full, and vision (if it can be elicited) is normal.

In orbital cellulitis, the findings of swollen, inflamed, and tender eyelids appear similar to those seen in preseptal cellulitis. In contrast, however, the globe itself is proptotic, injected, and chemotic. Ocular movements typically are both painful and restricted (secondary to inflamed orbital tissues
surrounding the globe); there may be papillitis (unilateral optic nerve swelling), an afferent pupillary defect, or decrease in vision secondary to swollen, infected tissues adjacent to the optic nerve. Children are febrile and appear quite ill.

Eyelid swelling in the pediatric population typically is secondary to infection (cellulitis), trauma (with soft-tissue swelling), allergy, or infiltration. History, examination, and focal findings readily diagnose soft-tissue swelling secondary to trauma. While impressive eyelid swelling may occur secondary either to infection or allergy, infected tissues are warm and tender while allergies cause pruritus, often swell rapidly after manipulation, and are cool, nontender, and usually soft to palpation (Table 32-1).

Although infiltrative processes in children are rare, both metastatic neuroblastoma (the most common metastatic orbital tumor in children) and rhabdomyosarcoma (most common primary orbital tumor in children) cause eyelid swelling, ecchymosis, and rapidly progressive proptosis. Both may be mistaken for trauma or cellulitis.

Congenital nasolacrimal duct obstruction occurs in approximately 6% of healthy children (Campolattaro et al., 1997). By far the most frequent cause of epiphora during the first several years of life is nasolacrimal duct obstruction. At birth, a thin membrane frequently persists at Hasner’s valve, located at the junction of the nasolacrimal duct and the nasal mucosa, causing obstruction of the nasolacrimal system. When an intranasal duct cyst is present, this causes a more marked obstruction in the early perinatal period, causing congenital dacryocele (dilated lacrimal sac). Presence of a dacryocele frequently causes bouts of acute or chronic low-grade dacryocystitis.

Epiphora secondary to nasolacrimal duct obstruction is often accompanied by an intermittent purulent discharge and crusted eyelids in the morning. Although a recent study contradicts the traditional teaching that newborns do not lacrimate at birth (Isenberg et al., 1998), symptoms usually do not manifest until 2 to 4 weeks of age. Symptoms of perinatal epiphora are usually related to a conjunctivitis (chemical or infectious). If the obstruction is above the nasolacrimal sac, only epiphora without purulent discharge may be noted. On examination, children have a prominent tear lake and may either have frank tearing or dried tear marks on their cheeks. Frequently pressure on the lacrimal sac causes expression of purulent material through the puncta.

Dacryocystitis may be either acute or chronic. In addition to epiphora and recurrent conjunctivitis as seen with simple nasolacrimal duct obstruction, dacryocystitis presents as an inflamed, tender mass over the lacrimal sac area, which may be associated with cellulitis.

Epiphora is nonspecific, but the most common cause of chronic epiphora is nasolacrimal duct obstruction. This diagnosis is supported by a history of persistent tearing, recurrent conjunctivitis, and the findings on examination as described previously.

Other causes of epiphora fall under the category of overproduction of tears and occur much less frequently than obstruction. However, when evaluating for epiphora, one should inspect the eye for signs of irritation that might be the cause of excessive lacrimation, including eyelid malformations, malpositioning of eyelids or cilia, and foreign bodies.

Primary care providers should rule out congenital glaucoma in a child with epiphora. Classic symptoms of congenital glaucoma include epiphora, blepharospasm, enlarged cloudy cornea, and photophobia. Photophobia results from glare produced by corneal edema and is probably the most reliable sign of the triad. Intraocular pressure is elevated, and palpation of the globe through the eyelids reveals a firm globe and buphthalmos. Congenital glaucoma usually is bilateral. If congenital glaucoma is suspected, immediate referral to an ophthalmologist should be made. The treatment of congenital glaucoma is surgical, and medical therapy merely temporizes until the surgery can be performed.

Initial treatment of nasolacrimal duct obstruction is conservative. With lacrimal sac massage and periodic topical antibiotics (Table 32-2) as needed to control discharge, a child may be observed up to 1 year of age unless symptoms are excessive. Most studies agree that by 1 year of age, 90% of cases have spontaneously resolved. Studies also have shown that spontaneous resolution of nasolacrimal duct obstruction after 1 year of age is unlikely (Nelson, 1998).

Primary care providers should teach nasolacrimal sac massage to parents. A finger should be firmly pressed on the sac (just below the medial canthus and under the orbital rim). Gentle pressure should then be exerted inferiorly to attempt to express lacrimal sac contents through the membrane at Hasner’s valve. A schedule easily remembered by parents, such as massage during each feeding period, should be recommended. Topical antibiotic drops or ointment (bacitracin ophthalmic ointment, erythromycin ophthalmic ointment, polysporin solution) should be prescribed whenever a child has purulent discharge.