Stye / Hordeolum

Ophthalmic Findings
- Pustules with erythema on the margin of the eyelid
- Localized tender area of swelling with a pointing eruption on the internal or external
side of the eyelid
- Tender upon palpation
- Pustular exudates
- localized, tender, erythematous, elevated area with a pointing eruption either on the inner or outer side
of the eyelid.
- Hordeolum are usually superficial, and centered on an eyelash

https://www.ncbi.nlm.nih.gov/books/NBK441985/
https://www.ncbi.nlm.nih.gov/books/NBK459349/#:~:text=Stye%2C%20or%20hordeolum%2C
%20is%20an,which%20is%20tender%20to%20palpation.

Chalazion
- A deep chalazion is caused by inflammation of a tarsal meibomian gland. A superficial
chalazion is caused by inflammation of a Zeis gland.
- Chalazia are caused by inflammation and obstruction of sebaceous glands of the eyelids.
While infection can cause the inflammation or obstruction that leads to a chalazion, the
lesion itself is an inflammatory lesion.
- Chalazia are inflammatory lesions that form when lipid breakdown products leak into
surrounding tissue and incite a granulomatous inflammatory response. For this reason, a
chalazion is also called a conjunctival granuloma. Meibomian glands are embedded in the
tarsal plate of the eyelids; therefore, edema due blockage of these glands is ordinarily
contained to the conjunctival portion of the lid. On occasion, a chalazion may enlarge and
break through the tarsal plate to the external portion of the lid. Chalazia due to blockage
of Zeis glands are usually located along the lid margin.
-
-
- slowly enlarging, nontender on palpation
- usually presents as a painless swelling on the eyelid for weeks or months
- PE findings:
o Physical findings consistent with chalazion include a palpable, usually non-tender
(though in acute inflammation there may be some associated tenderness), non-
fluctuant, non-erythematous nodule on the eyelid. The chalazion would be
expected to be less than 1 cm in size. It presents more often on the upper lid as a
single lesion, though multiple lesions are possible. Chalazia tend to be deeper
within the lid than hordeolum.
o Hordeolum are usually tender, superficial, and centered on an eyelash. The eyelid
should be everted as part of the examination to evaluate for an internal chalazion.
 Visual acuity should be assessed. If there is a pain of the globe, fluorescein
staining can evaluate for an associated corneal abrasion.

https://www.ncbi.nlm.nih.gov/books/NBK499889/

o
Basal Cell Carcinoma
- Basal cell carcinoma (BCC) is the most frequent malignant tumor of the eyelid, and it
accounts for ~80% of all malignant eyelid tumors
- Well-known risk factors of BCC include high levels of sunlight exposure and ultraviolet
radiation and increasing age
- typically presents as a shiny, pink- or flesh-colored papule or nodule with surface
telangiectasia. The tumor may enlarge and ulcerate, giving the borders a rolled or rodent
ulcer appearance. The most common sites for nodular basal cells are the face, especially
the nose, cheeks, forehead, nasolabial folds, and eyelids.
- Patients often give a history of crusting and recurrent bleeding, causing them to seek
evaluation.
- They are slow growing tumors
- The location of the lesion is noteworthy. Due to a relatively greater amount of sun exposure, BCC has
a predilection for the lower eyelid, followed by the medial canthus.
- It typically appears as an elevated growth with reddish, rolled up borders, prominent
blood vessels, and often a depression in the center.
-

Incidence rates for BCC also increase with age, with the median age of diagnosis being 68 years.

The prime etiological factor in the development of basal cell carcinoma is exposure to UV light,
particularly the UVB wavelengths, but UVA wavelengths can also be a factor.

Examination of the lesion includes assessment for:

 General appearance and extent of the lesion and periocular skin

 Distortion of eyelid architecture or eyelid malposition
 Presence of skin ulceration
 Madarosis (loss of eyelashes)
 Telangiectasias

 May be asymptomatic
 Ulceration and bleeding
 Non-healing skin lesion
 Skin crusting
 Paresthesia or anesthesia
 Eyelash loss (madarosis)
 Distortion of normal eyelid margin or tissue architecture
 - https://warwareyegroup.com/patient-education/eyelid-basal-cell-carcinoma/
https://www.ncbi.nlm.nih.gov/books/NBK482439/#:~:text=History%20and
%20Physical&text=Nodular%20BCC%20is%20the%20most,rolled%20or%20rodent%20ulcer
%20appearance.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445647/#:~:text=Basal%20cell
%20carcinomas%20(BCC)%20make,morbidity%20due%20to%20orbital%20invasion.

https://eyewiki.aao.org/Basal_Cell_Carcinoma

Pharmacologic
- Erythromycin ophthalmic ointment applied twice a day are beneficial for 7-10 days

https://www.ncbi.nlm.nih.gov/books/NBK482439/

INDIVIDUAL QUIZ

11-year-old with a 5-month recurrent fronto-temporal headaches. Visual acuity is OD 20/50, OS

20/100.

1-5. Ask important and pertinent questions to build your clinical history (5-10 relevant
questions, including necessary PMH/ FMH).

 Kailan nagsimula ang panlalabo ng mata?

 Mas Malabo ba ang paningin kapag nagbabasa ng malapit o nang mas malayo?
 Nagkakaroon ba ng panankit ng ulo at mga mata pagkatpos gumawa ng gaawin tulad ng
pagsusulat, pagbabasa, paggamit ng computer
 Mas nahihirapan bang makakita kapag madilim
 Para bang naka strectch ang mga nkikitang mo imahe
 Nagkaroon ba ng ibang mga simtomas tulad ng pamumula, pananakit ng mata, pagiging
sensitibo sa liwanag, aksidente sa mata, or opera sa mata?
 Mayron ba sa pamilya na may problema din sa mata katulad mo? Mayroon bang
diabetes sa pamilya?
 Madalas bang gumamit ng mga digital devices tulad ng cellphone, laptop or tablet

6-7. What important and relevant differential diagnoses do you have in mind? Explain
briefly.
Refractive errors are conditions where in there is problem in focusing of light accurately on the
retina due to changes in the shape of the eye. The most common types of refractive errors
include myopia (nearsightedness), hyperopia (farsightedness), astigmatism and presbyopia.
Myopia results in blurring of objects in a distance, hyperopia and presbyopia results in blurring
of objects that are close and astigmatism causes object to appear stretched out or blurred.
Other symptoms may include doubling of vision, headaches and eyes.

The most common presenting complaint of patient with errors of refraction are blurring of
vision for distance, for near or both. Clear near vision but blurred distance vision indicates
myopia. Hyperopes may complain of early visual fatigue when performing visual tasks.
Headache after prolonged use, is common with hyperopes and astigmatic but are non-specific.

 Myopia is the most common refractive error in children and young adults. It occurs
when the refractive power of the visual system is too high in relation to the length of
the eyeball. The focused image of a distant object forms in front of the retina and the
image is blurred at the fovea. Parent’s usually complains of a child reading books by
placing them closer to their faces, making mistakes when taking notes in class, difficulty
watching television from a distance of 3 ft, having repeated headaches.

For myopia, accommodative efforts would cause grater refractive power displacing the
image beyond the retina. Hence myopic patient requires less accommodation there for
less eye strain and headaches. So I considered this less likely

 Hyperopia is a common refractive error in children. It occurs when the refractive power
of the visual system is too small in relation to the length of the eye, the focused image
of the distant object therefore lies behind the retina and the image at the level of the
retina is unclear. Patient can be asymptomatic. Patient may also note esotropia. In
patient with total accommodative effort, patient may complained of varied amount of
tiredness of the eyes localized frontal or frontotemporal headache. It may also be
associated with photophobia and watering. Patient may also complain of sensation of
crossed eye but without any diplopia.

Since patient with hyperopia requires more accommodation in order to focus object at
the retina resulting to more eye strain and headache. Hence this diagnosis is more
likely

 Astigmatism is a common refractive error where refraction changes in different

meridians of the eye. Light rays passing through the eyes cannot converge in a particular
focal point but rather form focal lines. The light passing from the cornea does not
converge to a focus point on the retina. Patient usually presents with headache, pain
heaviness in the eyes, frontal headaches, difficulty focusing, transient blurring,
drowsiness and even nausea. Patient may also report of elongation of vision
 Astigmatism can also present with headaches and eye stains because of the need for
accommodation and greater refractive power at some point. However much less as
compared to hyperopia.

 Presbyopia is an age related farsightedness. The eye is restriced in its ability to focus on
close objects. The cause is due to the loss of elasticity of the ocular lens and structural
changes in the area of the zonular fiber and ciliary muscles. It usually begins around the
age of 40. Patient usually complain of difficulty reading of finer prints at the usual
reading distance. Patient report of improvement if the reading distance is increased
slightly beyond usual reading distance.. Patient often complain of headaches, squinting,
drowsiness and need for bright light when reading.

However because it is age related and the common onset is during the age of 40. It is
less likely the diagnosis

8. Give the most likely final diagnosis.

Hyperopia or far sightedness.

9-10. Manage the case.

The aims of management is to provide good rehabilitation with proper refractive

correction. Optical correction through the use of biconvex lenses (plus) are recommended to
converge the light rays at the retina.
Anticholinesterase agents such as diisopropylfluorophosphate and echothiopate iodide
have been use for accommodative esotropia and hyperopia to reduce a high accommodative
convergence to accommodation ratio and improve alignment of the eyes at near. These drugs
can mimic the accommodative effect of the plus lenses without the need of spectacles and
contact lenses
Reduction in visual demands are not able to reduce the levels of hyperopia but can help
to lessen the symptoms. Hence modification of habits and visual environment is useful as
adjustive therapy. These includes improving lighting, better quality of printed material.
Decreases temporal demands, optimal visual hygiene.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8275419/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5143802/#:~:text=The%20simplest
%20underlying%20refractive%20error,from%20the%20ideal%20of%20ca.

https://www.ncbi.nlm.nih.gov/books/NBK560716/
https://www.ncbi.nlm.nih.gov/books/NBK580529/