FIGURE 123.14 A patient with multiple chalazions, including one in the left upper eyelid draining spontaneously via the skin FIGURE 123.15 Chronic chalazion within left upper lid The treatment for both a chalazion and a stye is essentially the same Eyelash scrubs once or twice daily are helpful in mechanically establishing drainage Baby shampoo is applied to a washcloth and then used to gently scrub the base of the eyelashes while the eyelids are shut Warm compresses over closed eyelids four times daily for 10 minutes may be helpful, but is rarely tolerated well by younger children If a washcloth is used it will cool quickly and will need to be reheated while a gel pack will retain the heat for a longer period of time There is minimal evidence for antibiotics in the treatment of stye and chalazion in the absence of concurrent cellulitis, except in recalcitrant chronic cases In such cases a topical antibiotic ointment with coverage for coagulase-negative staphylococcal species ( Table 123.2 ) can be applied twice daily following eyelash scrubs to help reduce staphylococcal overgrowth If there is inadequate resolution after at least to weeks of medical management, incision and curettage by an ophthalmologist can be considered Nasolacrimal Duct Obstruction and Infection The nasolacrimal apparatus extends from the puncta in the eyelids to the nose and is responsible for tear drainage The most common cause of nasolacrimal duct (NLD) obstruction is incomplete canalization at the distal end of the system before it enters the nose NLD obstruction is the most common cause of persistent tearing and ocular discharge in children, occurring in up to 20% of all normal newborns NLD obstruction may rarely be complicated by inflammation or bacterial infection of the lacrimal sac (i.e., dacryocystitis), which is an ocular emergency Patients with NLD obstruction are usually younger than year of age, with a history of symptoms dating back to the first weeks of life Infants typically present with intermittent tearing and debris on the eyelashes The discharge is mostly mucus that has precipitated out of the tear film because of stagnation of tear flow, and is usually worse on waking In contrast to patients with conjunctivitis-associated discharge, the conjunctiva is rarely inflamed with NLD obstruction (i.e., no “red eye”) ( Fig 123.16 ) Older children often have epiphora (i.e., excess overflow of tears) without discharge The diagnosis can be confirmed by placing pressure on the lacrimal sac, which lies under the skin against the lacrimal bone between the medial canthus and bridge of the nose, which forces discharge out of the sac back onto the surface of the eye Dacryocystitis is characterized by erythema, swelling, warmth and tenderness over the lacrimal sac often extending into the medial lower lid ( Fig 123.17 ) and may lead to periorbital or orbital cellulitis, sepsis, and meningitis The most common causative agents include S aureus, S epidermidis, and alpha hemolytic streptococci It should be noted that almost all infants with dacryocystitis have an underlying dacryocele (i.e., lacrimal duct mucocele), a cystic dilatation of the lacrimal sac which is caused by both a distal and proximal obstruction in the nasolacrimal apparatus It often presents as a bluish mass before getting infected FIGURE 123.16 Left nasolacrimal duct obstruction Note discharge on medial lower lid and wet lower lid lashes The conjunctiva is noninflamed (no “red eye”) indicating that the child does not have conjunctivitis Over 90% of cases of NLD obstruction resolve spontaneously over the first year of life Lacrimal duct massage (i.e., applying moderate pressure over the lacrimal sac) is the first line of treatment Lacrimal duct probing or stenting may be required for select resistant cases Acute dacryocystitis is an ocular emergency which requires immediate antibiotic treatment and ophthalmology consultation FIGURE 123.17 Dacryocystitis in an infant with a dacryocele Erythematous, tender, swelling along the inferior medial canthal area representing inflammation of the nasolacrimal sac Suggested Readings and Key References General Bagheri N, Wajda BN, eds Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease 7th ed Philadelphia, PA: Wolters Kluwer; 2017 Periorbital and Orbital Cellulitis Botting AM, McIntosh D, Mahadevan M Paediatric pre- and post-septal periorbital infections are different diseases A retrospective review of 262 cases Int J Pediatr Otorhinolaryngol 2008;72(3):377–383 Hauser A, Fogarasi S Periorbital and orbital cellulitis Pediatr Rev 2010;31(6):242–249 Rudloe TF, Harper MB, Prabhu SP, et al Acute periorbital infections: who needs emergent imaging? Pediatrics 2010;125(4):e719–e726 Santos JC, Pinto S, Ferreira S, et al Pediatric preseptal and orbital cellulitis: a 10 year experience Int J Pediatric Otorhinolaryngol 2019;120:82–88 Conjunctivitis LaMattina K, Thompson L Pediatric conjunctivitis Dis Mon 2014;60:231–238 Richards A, Guzman-Cottrill J Conjunctivitis Pediatr Rev 2010;31(5):196–208 ... needs emergent imaging? Pediatrics 2010;125(4):e719–e726 Santos JC, Pinto S, Ferreira S, et al Pediatric preseptal and orbital cellulitis: a 10 year experience Int J Pediatric Otorhinolaryngol... probing or stenting may be required for select resistant cases Acute dacryocystitis is an ocular emergency which requires immediate antibiotic treatment and ophthalmology consultation FIGURE 123.17... Suggested Readings and Key References General Bagheri N, Wajda BN, eds Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease 7th ed Philadelphia, PA: Wolters Kluwer; 2017