Case 18 - Cornea, external disease, and anterior segment
82-year-old retirement home resident - Bilateral chronic red eyes - Burning and stinging - Lid margin crusting
An 82-year-old resident of a retirement home has chronically red eyes. She complains of burning and stinging in both eyes. The external view shown depicts the condition of both eyes.
Dry, flaky, scaly debris at lash bases (seborrheic blepharitis). COLLARETTES - golden- crusted fibrinous debris encircling individual lash bases = HALLMARK of staphylococcal blepharitis. Thickened hyperemic lid margins with telangiectasia. Inferior punctate keratopathy from staphylococcal exotoxins.
Staphylococcus aureus/epidermidis, Seborrheic dermatitis (Malassezia yeast), Rosacea (posterior blepharitis/MGD - treat with doxycycline), Demodex folliculorum (eyelash mites, cylindrical sleeves at lash base - increasingly recognized in elderly), Sebaceous gland carcinoma (MASQUERADE - biopsy if refractory/unilateral, especially in elderly).
Mixed anterior blepharitis: Seborrheic (dandruff-like scales, Malassezia-associated, scalp seborrhea) + Staphylococcal (collarettes, toxic marginal keratitis). Posterior blepharitis/Meibomian Gland Dysfunction (MGD) likely contributing -> evaporative dry eye.
Core (lifelong): warm compresses x 10-15 min BID + lid scrubs (diluted baby shampoo or commercial wipes). Topical: erythromycin/bacitracin ointment to lid margin; artificial tears/cyclosporine/lifitegrast for DED. Systemic: oral doxycycline 50-100 mg daily x 6-12 weeks for rosacea-associated MGD. Demodex: topical ivermectin (Xdemvy - FDA approved 2023) or tea tree oil. Office: IPL or LipiFlow for MGD.
Blepharitis is CHRONIC - lid hygiene is lifelong. Demodex increasingly recognized as dominant cause in the elderly (look for cylindrical sleeve collarettes). CRITICAL: unilateral blepharitis not responding to treatment in an elderly patient -> BIOPSY to rule out sebaceous gland carcinoma (the 'masquerade malignancy' with 30% mortality if missed). Rosacea-associated blepharitis responds well to oral doxycycline.
Findings Causes Dry, flaky, scaly debris at lash bases (seborrheic blepharitis). COLLARETTES - golden- Staphylococcus aureus/epidermidis, Seborrheic dermatitis (Malassezia yeast), Rosacea crusted fibrinous debris encircling individual lash bases = HALLMARK of staphylococcal (posterior blepharitis/MGD - treat with doxycycline), Demodex folliculorum (eyelash blepharitis. Thickened hyperemic lid margins with telangiectasia. Inferior punctate mites, cylindrical sleeves at lash base - increasingly recognized in elderly), Sebaceous keratopathy from staphylococcal exotoxins. gland carcinoma (MASQUERADE - biopsy if refractory/unilateral, especially in elderly). Diagnosis Management Core (lifelong): warm compresses x 10-15 min BID + lid scrubs (diluted baby shampoo or Mixed anterior blepharitis: Seborrheic (dandruff-like scales, Malassezia-associated, scalp 2 4 commercial wipes). Topical: erythromycin/bacitracin ointment to lid margin; artificial seborrhea) + Staphylococcal (collarettes, toxic marginal keratitis). Posterior tears/cyclosporine/lifitegrast for DED. Systemic: oral doxycycline 50-100 mg daily x 6-12 blepharitis/Meibomian Gland Dysfunction (MGD) likely contributing -> evaporative dry weeks for rosacea-associated MGD. Demodex: topical ivermectin (Xdemvy - FDA eye. approved 2023) or tea tree oil. Office: IPL or LipiFlow for MGD. TEACHING PEARL Blepharitis is CHRONIC - lid hygiene is lifelong. Demodex increasingly recognized as dominant cause in the elderly (look for cylindrical sleeve collarettes). CRITICAL: unilateral blepharitis not responding to treatment in an elderly patient -> BIOPSY to rule out sebaceous gland carcinoma (the 'masquerade malignancy' with 30% mortality if missed). Rosacea-associated blepharitis responds well to oral doxycycline.
