Ocular erysipelas is an acute infectious disease of the eyelid skin that develops when infected with b-hemolytic streptococcus, less often with Staphylococcus. Common symptoms for all forms are soreness and swelling of the eyelids, hyperthermia, general weakness. Diagnostics is based on ultrasound examination of the eye, biomicroscopy, laboratory tests (blood test, coagulogram). Drug therapy includes the appointment of anticoagulants, antiplatelet agents, antibacterial, hormonal agents and detoxification therapy. In severe cases, the autopsy of bullae, dermatomy, incision is indicated.
General information
Ocular erysipelas is an ophthalmopathology, in which there is an intensive increase in morbidity with a simultaneous increase in the frequency of relapses. The prevalence of the disease is 1.4-2.2 cases per 1,000 people. According to statistics, in 20% of patients with purulent-septic pathology of the eyes, the causative agent of infection is hemolytic streptococcus. In the general structure of erysipelas, the lesion of the eyelids is about 6-12%. The tendency to recurrent course is observed in 16-50% of patients. Pathology is more common among middle-aged women.
Causes of ocular erysipelas
The causative agent of erysipelas is usually b-hemolytic streptococcus of group A. Clinical manifestations occur with a decrease in humoral and cellular immunity. The main risk factors for development are:
- Metabolic disorders. Pathology often develops against the background of carbohydrate imbalance. Patients may have impaired glucose tolerance or diabetes mellitus.
- Trophic changes of the eyelid skin. A prerequisite for the occurrence of the disease are focal changes in the skin in the form of scars with zones of local ischemia.
- Violation of the integrity of the skin. Areas of damage on the eyelids become the entrance gate for infection. At the same time, the appearance of symptoms of erysipelas is preceded by intoxication manifestations.
- Bad habits. It is proved that the probability of pathology is higher in people who consume alcoholic beverages, narcotic drugs, as well as in smokers.
- Mycotic lesion. The spread of pathogens from the tarsal or bulbar zone of the mucous membrane in fungal conjunctivitis reduces the activity of local resistance factors, which contributes to the development of the pathological process.
Pathogenesis
In the mechanism of development of erysipelas, the leading importance is given to infection with b-hemolytic streptococcus. Primary lesion of the eyelids is extremely rare. As a rule, the inflammatory process spreads from neighboring areas of the skin of the face. Most often, the disease develops in persons sensitized to the pathogen antigens. A pronounced infectious-toxic syndrome is often limited to a local inflammatory focus. An important role in the pathogenesis of the disease is assigned to the violation of lymphatic and venous outflow, which significantly aggravates trophic disorders.
The addition of other bacterial pathogens (Pseudomonas aeruginosa, pyogenic streptococcus, coagulase-negative staphylococci) to the monoculture of streptococcus leads to generalization of surgical infection and chronization of the process. The role of Staphylococcus aureus in the development of non-destructive forms has been proven. In turn, hemolytic streptococcus provokes phlegmonous variants of the disease with a high tendency to destruction. In recent years, there has been a trend towards the formation of resistant forms to previously used antibiotics from the b-lactam group.
Classification
Erysipelas is an acquired pathology. There are primary, recurrent and recurrent variants of the course of the disease. From a clinical point of view , the disease is classified into the following forms:
- Erythematous. A clear line of irregular shape is determined, which allows differentiating healthy tissues from those affected by the pathological process. The restriction zone resembles “flames”. The skin is swollen, hyperemic.
- Gangrenous. On the surface of the affected eyelid, areas of ulceration are formed, from which purulent masses are separated. The patients’ well-being deteriorates sharply.
Depending on the nature of local manifestations, individual authors distinguish erythematous-bullous, erythematous-hemorrhagic, erythematous and bullous-hemorrhagic types of the disease. According to the prevalence of local changes, the following forms of the disease are distinguished:
- Localized. The affected area is limited by movable skin folds. Reactive changes in the surrounding tissues are uncharacteristic.
- Common. The pathological process extends to the ocular region, the skin of the face.
- Metastatic. The appearance of distant lesions (erysipelas of the lower extremities, scalp, face) is characteristic.
Symptoms of ocular erysipelas
Regardless of the course of the disease, patients complain of severe pain in the eye socket, general weakness, and an increase in body temperature to 38-40 ° C. Edema leads to limited mobility of the eyelids. Often, the development of a clinical picture is preceded by damage to the skin of the ocular region, erysipelas of another localization (face, lower extremities) or the persistence of the pathogen in the body. In the erythematous form, the skin is hot to the touch, sharply painful. Over time, itching and burning in the eyelid area occurs. Patients try to reduce the severity of the pain syndrome by covering the affected eye with a hand or bandage.
With a gangrenous variant of pathology, ulcerative defects are formed in the affected area. Purulent contents are separated from ulcers. An increase in regional lymph nodes is characteristic. After recovery, dense scars form on the site of ulcers. Due to a violation of the outflow of lymph, dense edema increases. In the erythematous-hemorrhagic variant, the affected surface bleeds, there is a symptom of “bloody dew”. The erythematous-bullous form of pathology is complicated by the rupture of the formed bulls with the separation of exudate. Relapses of the disease provoke a decrease in the overall resistance of the body.
Complications of ocular erysipelas
When the pathological process spreads to the orbital conjunctiva, purulent conjunctivitis often occurs. The disease may be complicated by phlegmon of the orbit. The lack of timely therapy leads to thrombosis of the orbital veins. In some cases, secondary optic neuritis is observed. The spread of infection beyond the skin contributes to the development of panophthalmitis, less often meningitis. After the treatment of patients with gangrenous form, there is a high risk of formation of dense scars. In case of violation of the outflow of lymph, lymphatic edema (lymphedema) of the upper eyelid or the entire ocular region may occur. Secondary elephantiasis is represented by fibredema.
Diagnostics of ocular erysipelas
The diagnosis is based on anamnestic data, the results of physical examination and special examination methods. Redness and swelling of the skin around the eye with the transition to palpebral conjunctiva is visually determined. The complex of instrumental diagnostics includes:
- Biomicroscopy of the eye. When examining the eyelid and the tarsal part of the conjunctival membrane, the ophthalmologist detects infiltration with separate foci of purulent masses. The injection of vessels of the bulbar and palpebral conjunctiva is visualized.
- Ultrasound of the eyes. Ultrasound diagnostics allows us to assess the depth of tissue damage and the prevalence of the pathological process. The technique also makes it possible to identify reactive changes in the posterior segment of the eyeball.
Laboratory diagnostic methods are used to select further treatment tactics and monitor the effectiveness of the therapy. Patients are shown to conduct:
- Blood test. A decrease in the number of platelets is determined with a normal content of other shaped blood elements.
- Coagulograms. The level of fibrinogen A, prothrombin index and time increase against the background of a decrease in the level of antithrombin III. Blood clotting time is shortened.
- Antibioticograms. Determination of the sensitivity of the causative agent of the disease to antibacterial agents allows you to prescribe the most effective drug of a narrow spectrum of action.
Differential diagnosis is carried out with blepharitis of allergic genesis and the initial manifestations of herpes zoster. A distinctive feature of allergic blepharitis is hyperemia and edema are not accompanied by the formation of ulceration sites and bullae. With the help of desensitizing agents, it is possible to completely stop the manifestations of pathology. With shingles, herpetiform rashes are localized along the course of the nerve trunk.
Treatment of ocular erysipelas
The purpose of therapeutic measures is the relief of the inflammatory process, the eradication of the pathogen and the achievement of stable remission. Conservative therapy can be used in isolation for mild to moderate severity of the disease or in combination with surgical methods for severe or complicated course. Medical treatment includes the appointment of:
- Antibacterial drugs. Penicillin antibiotics are used, with their inefficiency – macrolides, tetracyclines. The reserve drugs are fluoroquinolones. Systemic (intramuscular injections) and local (instillation into the bulbar conjunctiva zone) administration is indicated.
- Detoxification therapy. It is used for symptoms of general intoxication of the body. A 10% solution of calcium chloride is administered intravenously. The average duration of the course is 5-10 days.
- Hormonal drugs. Glucocorticosteroids are used to prevent relapses. The effectiveness of hormone therapy is due to the fact that patients have a dissociated violation of the function of the adrenal cortex, manifested by a decrease in the synthesis of glucocorticoids.
- Antiplatelet agents and anticoagulants. They are prescribed to prevent thrombosis. Medicines affect the activity of the blood clotting system. They are used under the control of coagulogram indicators.
- Immunomodulators. Medications are able to activate immunocompetent cells and affect cellular metabolism. The drugs of choice are natural immunostimulants.
- Vitamin therapy. The use of vitamins C, PP and B, which have neuroprotective and antioxidant effects, is recommended.
Indications for surgical intervention are considered to be low efficiency of conservative therapy, an increase in intoxication manifestations, a high risk of infection of surrounding tissues. Hormonal, antibacterial and immunomodulatory agents are used in the postoperative period. Surgical treatment includes:
- Decompression contour dermatomy. It is used for purulent-necrotic and bullous-hemorrhagic forms. With pronounced exudation, a drainage system should be installed. Necrosis foci are subject to resection.
- Making incisions in the area of inflammation. The technique is recommended for circular lesion. Longitudinal or transverse wave-shaped incisions are applied within the pathological focus throughout its entire length. At the end, a necrectomy is performed.
Autopsy of bull. It is performed with erythematous-bullous and bullous-hemorrhagic variant of pathology. After opening the bull, the evacuation of pathological masses is carried out, followed by drainage.
Prognosis and prevention
The prognosis with timely treatment is favorable. Patients with this pathology should closely monitor eye hygiene, avoid hypothermia. In the presence of other foci of infection, systemic antibacterial therapy is indicated. Specific preventive measures have not been developed. Non-specific prevention is reduced to the use of bactericidal agents for the care of the eyelids in the presence of microtrauma or cuts, compliance with the rules of asepsis and antiseptics when working with infected material. Patients with erysipelas of other localizations should wash their hands thoroughly before contact with the eyes.
