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COMPLETE HOW TO TREAT QUIZZES ONLINE
www.howtotreat.com.au
INSIDE
Eyelid
inflammation and
infection
Eyelid
malpositions
Eyelid lesions
Disorders of
eyelashes
Lacrimal system
Case study
THE AUTHOR
Eyelid and lacrimal disorders
DR FRENY KALAPESI
oculoplastic and ophthalmic
surgeon, Horsley Eye Clinic,
Personal Eyes, South Western
Eye Care and Westmead Hospital,
Sydney, NSW.
Introduction
THE eyelids frame our eyes and
have a characteristic contour and
shape, defining our appearance. In
addition to their aesthetic function,
they have the important mechanical
functions of protecting and lubricat-
ing the cornea and excluding foreign
bodies and trauma.
Malposition of the eyelids has an
aesthetic disadvantage but, more
importantly, can allow damage and
trauma to the cornea and poten-
tially the orbit. Untreated, eyelid
infections can progress to threaten
vision and even life.
This How to Treat offers infor-
mation on eyelid infections and
abnormalities of eyelid positions,
while also touching on eyelid lesions
and the lacrimal system.
Eyelid inflammation and infection
Preseptal cellulitis
PRESEPTAL cellulitis is defined as
infection anterior to the orbital sep-
tum. It appears as a unilateral red,
swollen eyelid. Infection involves
only skin and possibly the underlying
orbicularis muscle. In children, sinusi-
tis is the usual culprit. Other causes
include local skin trauma, including
an insect bite; spreading adjacent
infection, such as from a chalazion;
dacryocystitis; or even URTI. 1
Preseptal cellulitis needs to be dif-
ferentiated from more serious post-
septal, or orbital, cellulitis. Exclude
signs of postseptal involvement (see
orbital cellulitis, and box 1). Addi-
tionally, the appearance of a normal,
non-swollen optic disc helps exclude
postseptal involvement. 2
Optic nerve appearance can be
examined by slit lamp biomicroscopy

refer for imaging and admission for
IV antibiotics.
Box 1. Signs of optic nerve involvement
• Reduced vision
• A relative afferent pupillary defect (seen with the swinging torch test) Orbital cellulitis
• Reduced redness sensitivity (asking the patient to quantitate the redness in a
percentage form compared with the contralateral/normal side) Orbital cellulitis implies involvement
posterior to the orbital septum, and
can threaten vision and even life if
complications such as meningitis or
cavernous sinus thrombosis eventu-
ate. Causes include sinusitis, extension
from preseptal cellulitis or other local
infection, such as dacryocystitis, an
infected globe (endophthalmitis) and
dacryoadenitis, as well as spread of
infection following an orbital fracture
because of connections to sinuses, fol-
lowing local surgery and even haema-
togenous spread of infection. 2
The patient may be febrile and have
an elevated white cell count. Signs are
those seen in preseptal cellulitis, plus
• Reduced brightness sensitivity (asking the patient to quantitate the ‘brightness’
of a light source, in a percentage form, compared with the contralateral/ normal
side)
• Reduced colour vision plate determination, for example, Ishihara plate
interpretation performed monocularly
• Abnormalities in visual field, which can be subtle requiring formal perimetric
assessment
• A swollen or hyperaemic optic disc appearance
and documented with optical coher-
ence topography, measuring the neu-
roretinal rim and retinal nerve fibre
thickness.
In a child, a full assessment may
not be possible. Start treatment with
oral antibiotics. However, the clini-
cal threshold for requesting imaging
to exclude postseptal involvement
should be low. If improvement does
not occur within 48 hours and/or if
signs of systemic infection are present,
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