A 56-year-old female presents to the eye clinic with burning, itching and crusting in both eyes; she has experienced these symptoms for years but has noticed that lately they are worse. Her eyes appear red and irritated on most days. There is new photophobia and an increased foreign body sensation that has brought her to see you today, worse in the right eye. Her best-corrected visual acuity is 20/25 OU. Slit lamp examination reveals the following:
The photograph is consistent with which of the following conditions? Please choose between one of the following four answers. One is correct, the others are not.
The onset of symptoms in contact dermatitis typically follows exposure to an inviting agent. There is often itching, burning and stinging as in this patient, but there is typically profound violaceous edema, and minimal scaling.
Typical signs of Staphylococcal blepharitis include many of the features seen in the above photograph including scaling, crusting and erythema along the lash line, with collarette formation. Chronic inflammation is often punctuated by periods of acute exacerbation with worsening symptoms. Staph marginal keratitis is often associated with staphylococcal blepharitis; bacterial antigens are thought to trigger an immune response resulting in a sterile corneal infiltrate with a characteristic clear zone between the limbus and the cornea. A clear mechanism explaining the development of staphylococcal blepharitis has not yet been confirmed.
Bacterial keratitis and conjunctivitis
Although this patient's condition is caused by staphylococcal bacteria, the symptoms and signs are not in keeping with a conjunctivitis. Further, the corneal findings in the right eye are consistent with a sterile infiltrate versus a bacterial ulcer. This patient has had grumbling symptoms for a long period of time, with recent worsening. There are no significant risk factors for an acute bacterial infection including contact lens use or recent trauma to the eye.
Herpes Zoster Ophthalmicus
This is a common condition of older adults, and may affect the V1 nerve distribution. Cases of Herpes Zoster are unilateral, and respect the midline, following the affected nerve distribution. The rash is painful, with vesicles, crusting, edema, and even ulceration. The rash is generally accompanied by flu-like symptoms including malaise, headache and fever, with an onset over a few days.
Blepharitis is a condition characterized by chronic inflammation of the eyelid margin, afflicting all ages and ethnic groups but typically presenting in middle age.1
Blepharitis is regarded as both one of the most common ocular conditions and one of the most difficult to effectively treat; the typical course is chronic, with fluctuating severity. It is generally bilateral, and unilateral symptoms should signify an alternate diagnosis. It is often associated with dermatologic diseases including rosacea and seborrheic dermatitis.2