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Case 1: Molluscum contagiosum

A worried mother brought in her eight-year-old daughter who had a raised spot in front of her left lower eyelid (Figure 1). There was no irritation and no signs of eye rubbing or discharge.

On examination of the lid there appeared to be a slightly raised spot which was in line with the meibomian gland openings and it was thought that she might have a blocked gland, therefore hot compressions were recommended.

Two months later the spot had not changed so the mother brought the girl back to the practice to see whether it was some sort of growth on the eyelid. At this visit the spot appeared to have grown in size and the top had a white, cheese-like appearance. She was referred to an eye specialist with a possible diagnosis of molluscum contagiosum.

The eye specialist was also unsure of the growth and mentioned to the family that the options were removal of this spot under general anaesthesia or to leave it for eight weeks to see what happened. They decided to wait.

A month after seeing the specialist the girl came for another assessment as there appeared to be an increase in the size of the spot. At this visit there was a definite increase in the size of the eyelid lesion, with multiple nodular appearances on its surface (Figure 2). There were no other signs of conjunctival involvement or follicular involvement.

Pathopathology

Molluscum contagiosum is a skin disease caused by a DNA pox virus. Smallpox virus and molluscum contagiosum are unique to humans. In children the condition is caused by direct contact and in adults it is more likely to be through sexual transmission. There may be multiple lesions around the eyelids. The molluscum lesion appears as a pale waxy umbilicated nodule. The raised nodules may contain a material resembling cheese at the centre and this is seen quite clearly in this case.

Treatment is simple incision and curettage, especially where there were other signs and symptoms of ocular irritation and follicular conjunctival involvement. In the absence of other signs and symptoms it can be left alone when the nodules involute over three months to a year.

It should be differentiated from basal cell carcinoma which has an ulcerating and undulating centre and is more often associated with UV exposure.

Case 2: Bacterial infection

A 65-year-old, non-contact lens wearer came in complaining of a red, watery and sticky eye for a day or two. His general health was fine and there was no previous history of an eye infection.

The patient presented with multiple grey, white corneal lesions, approximately 3-10mm in diameter. These were located in the sub-epithelial to superior stromal region of the cornea. The lesions were arranged in a crescent around the inferior limbal margins. The conjunctiva was grade 2-3 hyperaemic and the palpebral conjunctiva was inflamed (Figure 3).

Treatment

He was referred to his GP with a diagnosis of bacterial infection. He was treated with chloramphenicol drops (every two hours for the first two days and then every four hours for the next three days) he was seen back at the practice in five days. The improvement in the hyperaemia after five days was apparent (Figure 4). A week later following the use of the drops four times a day the improvement was again remarkable (Figure 5). A week without drops and the redness was non existent and the epithelial deposits gone (Figure 6).

The lesions were very similar in appearance to adult inclusion conjunctivitis but this was disregarded on the basis of the patient's age since, chlamydial/adult inclusion conjunctivitis affects young adults during sexually active years. A diagnosis of acute bacterial conjunctivitis was made, together with marginal keratitis. Bacterial conjunctivitis will give rise to red, sticky eyes. It is present at any age. Contact lenses are responsible for a high percentage of corneal infection.

Marginal keratitis is commonly associated with staphylococcal blepharitis and facial rosacea. Middle-aged people are more commonly affected compared to children. The self-limiting lesion/ulcer is non-infectious and it is thought to be due to hypersensitivity reaction to staphylococcal exotoxins. Anti-bacterial eye drops are the first port of treatment and this worked remarkably well in our patient. ●

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