Malassezia, commonly known as “needle’s eye” or “blepharitis”, is an acute, painful, purulent, nodular inflammatory lesion of the eyelid glands and is one of the most common eye diseases in clinical practice. Because it is so common, every ophthalmologist is able to diagnose and treat the disease, but there is no uniformity in diagnosis and treatment philosophy and specific tools, such as whether to apply cold or hot compresses in the early and late stages, drug selection, whether to treat surgically or conservatively, what is the timing of surgical incision, why does mydriasis recur, how to prevent recurrent mydriasis from diet and lifestyle habits, whether to diagnose mydriasis or chalazion, and whether to diagnose pediatric mydriasis. The authors will discuss how the treatment of pediatric wheals differs from that of adults, and so on.
In this article, we will discuss each of these issues in an easy-to-understand manner, based on the author’s clinical experience in the treatment of mydriasis and the many Chinese and Western medical treatises he has read.
The subcutaneous tissue of the eyelid is lax, where tissue exudate tends to collect during inflammation and where the inflammatory response tends to spread. There are many openings for sweat glands (Moll’s glands) and sebaceous glands in varying numbers near the lid margins, and the infection of these two glands is known as “exophthalmos”. Inflammation of the lid glands is called “internal blepharitis”.
In general, external blepharitis is a small, superficial swelling with mild pain and early localized itching, with a short septic cycle, and the pus is first found on the skin of the eyelid or at the base of the eyelashes, with a quicker recovery. The causative organisms are mainly staphylococci, especially Staphylococcus aureus, which should be treated with antibiotics that are primarily anti-Gram-positive (e.g., penicillins and macrolides), but not antibiotics that are primarily anti-Gram-negative (e.g., quinolones or aminoglycosides).
However, penicillins are limited in drug preservation and need to be dispensed one day at a time, while macrolides such as erythromycin have weaker antibacterial power and their ophthalmic ointment is too viscous, which is not conducive to glandular opening and glandular excretion, thus affecting the clinical application. Therefore, clinicians can only prefer quinolones such as ofloxacin, levofloxacin, and gatifloxacin ophthalmic drops and ophthalmic gels with weaker anti-Gram-positive bacterial power and wide and convenient topical application.
Here the authors emphasize that clinicians have a preference for aminoglycosides such as tobramycin eye drops, especially for pediatric mydriasis, that quinolone preparations affect the development of children and abandoned, this is unfounded. First of all, quinolones local (eyelids and conjunctival sac), a small amount (4-8 drops / day), low concentration (concentration is much lower than the systemic oral and intravenous drip), a short time (mostly within a week) application, through the skin and mucous membrane pathway absorption, the systemic impact is minimal, or even insignificant, while pediatric wheals is a key issue that doctors and parents should face directly, doctors should not pick the sesame seeds and lose the The doctor can neither pick the sesame seeds and lose the watermelon, nor can he seek farther away. In addition, the quinolone antibiotics themselves are very weak against gram-positive bacteria, such as then replaced by the even weaker aminoglycoside antibiotics, like a drop in the bucket.
Third, the bacterial infection is not a skin infection, but an infection of the subcutaneous tissue, eye drops in the skin and conjunctival sac, the effective concentration of its own penetration to the surface of the infected lesion is very low, there is the suspicion of scratching the itch, if you then switch to a drug with weaker antibacterial power, it is far from being lost. In addition, there are treatments using iodine applied topically to the eyelid skin, which is effective for early external wheals, but less effective for the deeper internal wheals.
There is a long-standing debate about whether cold or hot compresses should be applied to mydriasis, and even in formal ophthalmology textbooks such as the undergraduate and graduate editions of Ophthalmology and Chinese Ophthalmology, there is no uniformity of opinion. Some people think that cold compresses should be applied, even with ice, for two reasons: one is that local inflammation is mostly red, swollen, hot and painful, a “fire” image, so that cold compresses can reduce local symptoms; one is that wheals are bacterial infectious inflammation, high temperature is conducive to bacterial reproduction, lowering the temperature can naturally inhibit bacterial reproduction, thereby reduce the inflammation.
Some people believe that hot compresses, hot compresses can promote local blood circulation, accelerate the local collection of anti-inflammatory cells and the absorption of pus and toxins, in addition, hot compresses can effectively clean the local gland mouth blockage, promote the discharge of glands and inflammatory substances, “flowing water does not rot, the household pivot is not worm-eaten” meaning.
I advocate early hot compresses, not cold compresses, septic phase is neither cold compresses, nor hot compresses, for the following reasons: cold compresses can reduce the temperature, but shows that the operation of poor patient tolerance, can not last; cold compresses although local inhibition of bacterial reproduction, but can not effectively kill bacteria; wheals swelling into because of the local Ying Wei is not harmonious, Qi and blood does not run smoothly, local stagnation, depression and fire, cold compresses can be cool to curb the heat potential, that is, the old people say “cold pack fire”, as if closing the door to catch a thief, closed door to keep the invasion, so that the fire can not be dispersed, and local stagnation into nodules.
Ask, if the wheals are cold because it is a school of heat, then in daily life children with colds and fevers, why do the common people not dare to use cold water to cool the whole body bath, but use warm water to scrub? Because the cold water cooling, sweat hole closed, heat does not disperse, depression and fire, body temperature increased, so counterproductive, like pouring oil on the fire, become other diseases.
Therefore, the treatment should be based on the fundamental treatment of “fire and depression”. Fire is not only to clear the fire, but also to disperse the fire and relieve it. However, clinical treatment not only cold compresses, and to be cold antibiotic eye drugs such as ofloxacin, tobramycin eye solution, often did not control the disease, but also may lead to the late stage of the wheals do not completely recede, and the formation of local like wolfberry, hard texture, clear borders, several months does not recede light red nodules. Of course, at the stage of suppuration of the wheals, neither cold compresses nor hot compresses are advocated, as the inflammation is intense at this time, and hot compresses may encourage bacterial reproduction and aggravate the inflammation.
In the early stage, the inflammation of wheals is light, often through local treatment can be quickly cured, but for the immune system is relatively low in children and the elderly, weak, diabetic patients, oral hormone and other immunosuppressive patients, etc., you can take oral Chinese medicine to support the righteousness and eliminate evil, specific treatment such as clearing heat and dispelling wind, harmonizing the Ying and Wei, benefit Qi and blood, drain heat and pass the internal organs. Other treatment methods such as ultrashort wave physiotherapy, bloodletting at the ear tip and bloodletting at the back reaction point can be used as auxiliary treatment.
The main manifestation of the suppurative stage of wheals is the localized pus head and the fluctuating softness of the inflamed area to touch, so the treatment should be incision and drainage of pus, or even the addition of drainage strips to promote the elimination of pus. If the pus is not incised, squeezing to drain the pus is forbidden because the eyelid and facial veins do not have venous valves, and squeezing may cause the bacteria to enter the blood vessels and cause cavernous sinus thrombosis or sepsis, which can be life-threatening and is called “walking yellow” or “middle yellow” in Chinese medicine.
For patients with relatively low immunity, the combination of oral antibiotics and clearing heat and fire, tory burch outlet herbal treatment, if it leads to orbital cellulitis, sepsis, should be actively systemic and local Chinese medicine Western combination of treatment, should not be underestimated.
In clinical cases where the inflammation has been controlled but the surgical opening is not closed, or where the pus has been drained but the surgical opening does not heal for a long time, the clinician is at his wits’ end.
The human skin, digestive tract, lid margin, conjunctival sac and so on are co-existing many conditional pathogenic bacteria, these bacteria usually do not cause disease, and the human body “peaceful coexistence”, only when the body’s immunity is low, self-defense ability declined, such as plain unhygienic, diet, spicy, vegetarian Yang Sheng or Yin deficiency fire, the immunity of relatively low children This can lead to dysbiosis and can lead to ocular eruptions, blepharitis, and pink eye, which can be recurrent, occurring in the upper, lower left, and right eyelids at the same time or alternately, and can even persist for a long time.
This is characterized by a relatively insidious onset, mild symptoms of redness, swelling, heat and pain, but frequent and recurring eruptions of eruption, less susceptibility to suppuration, long-lasting healing, aversion to cold in the body and extremities, a dry mouth with little drinking, or a dry mouth with no desire to drink, a diet that is hot and cold, but easy to get hot when eating spicy foods, and even sores on the mouth and tongue when eating melon seeds. This kind of patients or long-term topical antibiotic eye drops, or surgical incision to drain the pus, the effect is not good, so the physician can not do anything. In fact, most of these patients are Yang deficient and Yin strong, deficient Yang floating upward, hot up and cold down, the fire of dragon thunder, of course, the treatment of cold to clear the fire is not effective, at the moment seems to be effective, a few days later the symptoms relapse or even aggravate, the correct treatment should warm the kidney Yang, leading fire downward, the only long-term solution.
Some primary care physicians use hormone-containing eye medications when they see localized edema of the eyelids and conjunctiva, treating hormones as a “miracle drug” to eliminate edema, which is not desirable. Edema is the result of infection, not the cause, and when the infection is eliminated, the edema will naturally subside, not to mention that hormonal drugs can cause local immune deficiency, ocular surface damage, dysbiosis, persistent corneal epithelium, cataracts, glaucoma, and mild drooping of the eyelids (leading to Muller’s muscle weakness). Incidentally, the abuse of systemic and topical antibacterial and hormonal drugs in recent years has led to a marked increase in the incidence of fungal keratitis, and it is more difficult to treat than before.
Patients with recurrent and multiple eruptions often have systemic symptoms or indications, so they cannot be treated locally alone, but should be treated with a combination of local and systemic therapy in order to cure the root cause.
Pediatric multiple and recurrent wheals have their own peculiarities and are different from adults. The I Ching says: “To the Kun Yuan, all materials are born, it is obedient to bear the sky. Kun is thick and carries things, and virtue is boundless”. Children’s internal organs are delicate, and their vital energy is not yet full. In particular, the spleen and stomach of the Kun earth, which is the essence of the later heaven, are not full, so they are easily injured by food accumulation and drugs. If the spleen and stomach in the middle jiao is weak and cannot run up and down to mediate the qi and blood (one qi flows around, the earth pivots on the four dimensions), the qi and blood lives up and down, depressing and turning into fire, so it is easy to suffer from wheat granuloma, at this time can not be in order to clear the heat and fire, but to give cold drugs to hurt the spleen and stomach, resulting in more deficiency of the spleen and stomach, then all the diseases bee up, the loss is not worth it. However, one of the current domestic medical oddities in China is the abuse of antibiotics, the slightest cold and fever, easily oral or intravenous drip antibiotics, cold injury in. Children’s internal organs are very delicate, and drugs make the “virtuous” spleen and stomach damaged, just like the tender seedlings in spring, injured by the cold air that comes again, can they grow strong?
The clinical confusion is about the differentiation of wheals and chalazion. The key to differentiating between wheals and chalazia is that they are caused by bacterial infections, while chalazia is caused by a local accumulation of lipids in the lid gland. The key to differentiating the two is the rapid onset and short duration of the disease, which is red, swollen, painful, with unclear borders and can become purulent later in life, whereas chalazion has an insidious onset and long duration, with normal local skin color and clear borders, which can be easily identified by clinicians through these typical symptoms.
However, if the chalazion is mistreated, the boundary will be clear and red nodules will be formed in the late stage, which will not heal for a long time and will be easily diagnosed as chalazion; chalazion is called “phlegm nucleus” in Chinese medicine, which is a pathological product and is a “foreign body” for the organism, and the organism has the ability to identify and remove the “foreign body”. The body has the ability to identify and remove the “foreign body”, so even if there is no co-infection at the later stage, local redness and swelling can occur, and even ulceration, the discharge is not pus, but blood or granulation tissue, this is the process of softening and absorption or discharge of the chalazion, not co-infection, this is non-infectious inflammation. Of course, “flowing water does not rot, the household hub is not worm-eaten”, in the late stage of chalazion, secretions for a long time, can be combined with bacterial infection and redness, swelling and heat pain, at this time is actually wheals and chalazion “combined disease”.
As for the prevention, there are the following points.
One, local cleanliness, so that the gland mouth is open, ;
Second, diet moderation, less spicy hot bo;
Third, to improve the body, “deficiency is the tonic, the real is the diarrhea, hot is cold, cold is hot”;
Fourth, prevent the abuse of drugs. Condition-causing bacteria in the lid margin and conjunctival sac itself coexist with people, physicians can not hope to kill all bacteria through antibiotics, which may be counterproductive, “press the gourd to float the dipper. Just as there are cancer cells in the body itself, we should only seek to “peacefully coexist” and not to “get rid of the evil”.
Before treating the disease, we should first protect its root, especially for children, treating the spleen and stomach is the first priority;
Sixth, pay attention to keep the bowels open, especially for children and the elderly, “instead of raising soup to stop the boiling, it is better to pull the bottom out of the kettle”;
Seven, to solve the problem, instead of looking for external causes, it is better to investigate the internal causes, instead of exogenous antibiotics to antibacterial, it is better to enhance their own antibacterial ability.