Mexico Medical Student |

A male in his mid-30s presents to an ophthalmologist complaining of left lower eyelid pain that began 2.5 days ago. The patient denies any history of similar symptoms. He also denies any discharge from the eye or exposure to any foreign substances, particulate or chemical. The patient reports that around the same time of the beginning of symptoms, his toddler daughter hit him inadvertently while playing, causing his glasses to hit the bridge of his nose on the left side, but denies direct trauma to his eyeball or eyelid. The patient also reports chronic use of loratadine (10mg qd) and occasional use of pseudoephedrine HCl (60-120mg/day in divided doses) for nasal congestion due to atopic seasonal allergies.

On physical examination, the patient is noted to have normal and stable vital signs. The examination of the eye reveals mild conjunctival hyperemia of the left eye without discharge. The medial aspect of the lower lid reveals non-fluctuant, slightly indurated swelling that is painful to palpation. Eye motion is grossly intact without pain.

What is the diagnosis?

This place is reserved for the final answer. I’ll give until noon on Saturday (~36h), or until the first person gets it right.

(picture below is 24h after picture above)

OK! We have a winner! Jon Mikel Iñarritú, a Mexican surgical resident down the road in Mexico City (and on his birthday, no less!) named it correctly: a blockage of the meibomian gland!

First things first: yes, that’s me and my left eye seemingly developing a central nervous system, and yes, it hurt like hell. But to put the cart before the horse, let me say first off that all is well and I (eye) do not look so freakish anymore. I did go to the opthomologist’s office with the attitude of “Stab this thing and let’s get it overwith,” thinking it was a stye, and the draining/excision/etc. of said ugliness would promote immediate relief. I’d do it myself, but something about taking an 11-blade to your eye with a mirror just kicks in some kind of self-preservation mode that prevents one from even thinking about such insanity for more than a second or two. I pictured the eye doc with little Barbie-sized scalpels for the delicate job. Well, nothin’ doin’.

But back to my case study, what on earth is a meibomian gland? Well, there’s a whole row of them in each eyelid, and it’s the name of the gland that gives oil to your conjunctiva and tears. I didn’t even know tears were a multi-component thing from different glands, just the salty, watery liquid from the tear (lacrimal) duct. However, if the watery part wasn’t mixed with the oily component of the meiobian gland, your tears would evaporate off of your eye way too quickly. When the meibomian duct gets blocked, much like a hair follicle being externally plugged, a physical buildup occurs along with swelling and pressure. When you have dry eyes (such as from allergies or from side-effects of medications, as mentioned in the case), all the tear-component glands kick into overdrive. That’s one way this problem can become clinically apparent.

Although the area is inflamed and swollen, this is not a hordeolum (stye), which is an eyelid pimple, essentially. The oils produced by the meibomian gland are sterile, so there’s no infectious process, usually. However, prolonged stagnation can leave a medium for bacteria, so therapy usually includes topical antibacterial eye drops, just to be safe (mine was a mix of abx and corticosteroid to help control the local swelling, but you’d have to be sure there’s no infection first or the steroid will do more harm than good).

The treatment for an uncomplicated case like this is conservative: warm compresses every few hours to liquify the hardened oils and allow normal drainage to continue. Uncomplicated blockages almost always resolve with this simple therapy. If the problem is more pronounced, vision is affected, a secondary infection has taken hold, etc. then obviously, all bets are off as you have a potential date with some invasive instrument. With chronic blockages or for those predisposed (usu. increased age), a chalazion will form. These can take months to resolve, but are as benign as the original acute inflammation process. Thankfully, I didn’t have to deal with this!!

Well, thanks for playing–I hope this was somewhat educational. I know that I learned more about the eye through this–much more so than I intended given my temporary leave from school. But this should serve to prove that at least for me, school is in session always! On that note, I encourage you to read the eMedicine article about this instead of relying on my Readers’ Digest version. I’ll leave the esoteric world of optho to others!