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Full text and additional images for Herpes Simplex Virus Blepharitis are available in VisualDx.
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A Differential Diagnosis of the Swollen Red EyelidA  This is a corrected version of the article that appeared in print.
Herpes zoster (or simply zoster), commonly known as shingles and sometimes referred to as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe. Varicella zoster virus can become latent in the nerve cell bodies and less often in non-neuronal satellite cells of dorsal root, cranial nerve or autonomic ganglion, without causing any symptoms.
Although the eyelids may be involved with many skin conditions, the most common are listed here.
A definitive diagnosis usually can be made on physical examination of the eyelid and a careful evaluation of symptoms and exposures. In the United States, it affects 10 to 20 percent of children and 1 to 3 percent of adults,28 with eyelid involvement in approximately 15 percent of cases.29ETIOLOGYThe etiology of atopic dermatitis is thought to involve a combination of complex genetic, environmental, and immunologic interactions.
It may be classified according to anatomic location: anterior blepharitis affects the base of the eyelashes, whereas posterior blepharitis involves the meibomian gland orifices. Although these conditions are less common causes of eyelid edema than contact dermatitis and atopic dermatitis, immediate recognition and treatment are critical to prevent vision loss and other serious complications, such as meningitis and cavernous sinus thrombosis.An understanding of the anatomy of the eyelid is important in distinguishing preseptal from orbital cellulitis. This condition may present with swollen eyelids similar to cellulitis; however, it most often occurs bilaterally and concurrently with swelling of other distensible regions of the body, particularly other facial structures and the extremities. The initial infection with varicella zoster virus (VZV) causes the acute (short-lived) illness chickenpox which generally occurs in children and young people. Years or decades after a chickenpox infection, the virus may possibly break out of nerve cell bodies and travel down nerve axons to cause viral infection of the skin in the region of the nerve.
Antiviral drug treatment can reduce the severity and duration of herpes zoster if a seven- to ten-day course of these drugs is started within 72 hours of the appearance of the characteristic rash. Blepharitis is often associated with other disorders such as rosacea, seborrheic dermatitis, and keratoconjunctivitis sicca.35ETIOLOGYThe exact etiology of blepharitis is unknown. The orbital septum is a sheet of connective tissue that extends from the orbital bones to the margins of the upper and lower eyelids37; it acts as a barrier to infection deep in the orbital structures38 (Figure 4). The virus may possibly spread from one or more ganglia along nerves of an affected segment and infect the corresponding dermatome (an area of skin supplied by one spinal nerve) causing a painful rash.


There is increased lacrimation in severe cases.The spectrum of ocular herpetic disease also includes conjunctivitis, iritis, and keratitis.
Orbital cellulitis is a severe infection presenting with proptosis and ophthalmoplegia; it requires hospitalization and intravenous antibiotics to prevent vision loss.
Anterior blepharitis is often attributed to staphylococcal infection or seborrhea, whereas posterior blepharitis generally results from meibomian gland dysfunction.35DIAGNOSISPatients with blepharitis will have erythematous and mildly edematous eyelid margins. Infection of the tissues superficial to the orbital septum is called preseptal cellulitis, whereas infection deep in the orbital septum is termed orbital cellulitis.38 Distinguishing between the conditions is important in determining appropriate treatment. It typically is unilateral and presents with tenderness, erythema, and localized swelling of the lid margin.2,38An internal hordeolum is a staphylococcal infection of a meibomian gland.
Although the rash usually heals within two to four weeks, some sufferers experience residual nerve pain for months or years, a condition called postherpetic neuralgia.
Epithelial keratitis involves only the superficial layer of the cornea and although less severe still can lead to scarring and vision loss.
Less serious conditions, such as contact dermatitis, atopic dermatitis, and blepharitis, are more common causes of eyelid erythema and edema. Inciting or exacerbating factors include aeroallergens, chemicals, foods, and emotional stress. Soft, oily, yellow scaling or, rarely, brittle scaling around the lashes distinguishes blepharitis from other causes of eyelid inflammation. It is unilateral and presents with pain, eyelid edema, and erythema more diffuse than that of an external hordeolum.2,38[corrected]A chalazion is a sterile nodular lipogranulomatous inflammation of a meibomian gland. Exactly how the virus remains latent in the body, and subsequently re-activates is not understood. Stromal keratitis, however, involves deeper layers of the cornea and also may lead to vision loss.Primary ocular HSV infections occur most often in children between the ages of 6 months and 5 years, and such infections almost always present as blepharitis or blepharoconjunctivitis. These less serious conditions can often be managed with topical corticosteroids and proper eyelid hygiene. Patients may have itching, irritation, and burning.2,36 Culture of the eyelid margins may be indicated for patients with recurrent anterior blepharitis and for those unresponsive to therapy. It is painless and nonerythematous.2 First-line treatment in all of these conditions includes warm compresses to encourage localization and spontaneous drainage.
They are differentiated on the basis of such clinical clues as time course, presence or absence of irritative symptoms, scaling, and other skin findings.


Biopsy to rule out carcinoma may be needed in particularly recalcitrant cases.35TREATMENTEyelid hygiene is the mainstay of treatment. Warm compresses are recommended, followed by gentle massage to express meibomian secretions. Such therapies include clindamycin (Cleocin), trimethoprimsulfamethoxazole (Bactrim, Septra), doxycycline (Vibramycin), and minocycline (Minocin). Recalcitrant lesions may require ophthalmology referral for incision and drainage.43ROSACEARosacea is a chronic skin condition most commonly affecting adults in their fourth and fifth decades of life.
Corneal involvement with HSV necessitates treatment with antiviral agents to prevent complications.Differentiate this condition from preseptal or orbital cellulitis on the basis of vesicles and ulcerations. Benign, self-limited eyelid nodules such as hordeola and chalazia often respond to warm compresses, whereas malignancies require surgical excision. For patients with staphylococcal blepharitis, a topical antibiotic applied at bedtime for a week or more may speed resolution.
Cellulitis may be suspected in patients with a red, swollen eyelid, although dermatitis is a more common cause. In some cases, the vesicles can be very subtle or have previously ruptured to form erosions, complicating the diagnosis (Figure 6). The differential diagnosis of eyelid edema is extensive, but knowledge of the key features of several potential causes can assist physicians in diagnosing this condition (Table 1).
It is a painful maculopapular rash, with vesicles, crusting, ulceration, erythema, and edema. These tumors are found most often on the upper eyelid and caruncle,50 and they are more aggressive than basal cell or squamous cell carcinoma.
These tumors are treated with wide excision.SYSTEMIC DISORDERSSystemic disorders such as myxedema, renal disease, congestive heart failure, and superior vena cava syndrome may manifest with periorbital edema. Generalized or regional edema as well as other signs and symptoms consistent with each respective disease should also be apparent.



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