Erythema, swelling near the eye in a 6-week-old female
A 6-week-old female presents with the sudden-onset of erythema and swelling near the left eye. The area was noted the day before to be a bit swollen, with the lids of the left eye being stuck together, and more tearing than usual.
The next morning, the eye had more swelling and erythema with some yellowish material in the eye. She was then taken to her primary provider, who routed her through the ED, where she was given a dose of ceftriaxone and admitted to the hospital.
James H. Brien
Her past medical history was positive for the previous diagnosis of left lacrimal duct stenosis. Otherwise, she has been healthy, with up-to-date immunizations and no history of injury or insect bites. Her family history is unremarkable, including no sick contacts.
Examination reveals normal vital signs, and a mildly fussy baby, with a well-circumscribed, swollen, erythematous mass, just inferior and medial to the left lower lid, with a yellowish color seen in the center of the lesion, under shiny overlying skin (Figures 1 and 2). There was a scant amount of yellowish discharge in the left eye. The rest of her examination was normal.
Source: Brien JH
This is a case of dacryocystitis (C); an infection usually involving the lacrimal sac, near the medial canthus, and occasionally more distal within the duct (Figure 3). It is usually secondary to stasis of tears in the duct due to lacrimal duct stenosis, allowing bacteria, usually Gram-positive cocci, to establish an infection. Symptoms can range from minimal irritation, to severe pain with surrounding cellulitis (Figure 4).
The case presented with a large, but well-contained area of erythema and swelling, with normal-appearing skin beyond the lesion. Management initially is medical, with antimicrobial therapy directed at Gram-positive cocci, unless the patient is immunocompromised. Then broad-spectrum antibiotics should be used. An attempt should be made to culture any material draining from the lesion, however, this is not always possible. One should resist the temptation to squeeze out the pus or incise and drain this lesion, as the lacrimal system is very delicate, and can be easily damaged. All procedures should be left to an ophthalmologist.
Neonates (Figure 5) and young infants should usually be admitted for empiric IV antimicrobial therapy initially, but older children can often be safely treated with oral antibiotics, or perhaps only topical ophthalmic antimicrobial agents and warm compresses. However, if this does not result in rapid improvement, I would recommend referral to an ophthalmologist.
Dacryoadenitis is inflammation of the lacrimal gland. The etiology can be viral, bacterial or inflammatory. An example of viral dacryoadenitis is seen in a patient with influenza (Figure 6). Bacterial dacryoadenitis is frequently associated with injury to the lacrimal gland, and may involve other surrounding tissues (Figure 7, an injury with a pencil to the gland). In either case, the swelling of the gland will produce distortion of the lateral upper lid, resulting in an S-shaped upper lid margin, as the swollen gland pushes the lateral aspect of the lid in a downward direction. Treatment will depend on the cause.
An internal hordeolum results from obstruction and infection of a meibomian gland, usually within the upper lid (Figures 8 and 9), but can, less commonly, involve the lower lid (Figure 10). Simple obstruction of the gland may lead to a chalazion, a sterile cyst. If it becomes infected, then it may be colloquially referred to as a “stye.” However, most reserve use of that term for the more common external hordeolum (Figure 11), which involves the glands of Zeis, named after Eduard Zeis, a German ophthalmologist in the 19th century. These problems may be best managed by ophthalmologists, but in the meantime, a topical antimicrobial ointment can be used. If there is surrounding erythema, indicative of preseptal cellulitis, then oral antimicrobial therapy or admission for IV anti-staphylococcal antibiotics may be needed. It would be a judgment call.
Preseptal cellulitis, as we usually think of it, results in a soft tissue infection of the structures anterior to the orbital septum. This may be a result of an injury (Figure 12) or bacterial sinusitis, or spread from one of the conditions mentioned above. Hematogenous spread of bacteria to the tissues around the eye was fairly common prior to the use of Haemophilus influenzae type b (Hib) vaccine. Remember, Haemophilus is Greek for “Blood Loving,” and was a common cause of septicemia before use of the Hib vaccine. As a result, this is very uncommon nowadays due to the success of the vaccine and herd immunity.
For more information:
James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: firstname.lastname@example.org.
Disclosure: Brien reports no relevant financial disclosures.