SPEX Practice Questions

Based on the National Board of Medical Examiners Special Purpose Exam format.

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Sample Stem:

A 56-year-old man complains of chronic, bilateral burning, itchy, scaly eyelids that have worsened in the last 2 days. The patient also notes that the crusting is worse upon waking, and throughout the day he experiences what he describes as a "foreign body sensation." The appearance of the crusts is seen accumulating around the cilia (see Figure).

special purpose exam review question blepharitis

Which statement is true regarding this condition?

SPEX Exam Answers

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Answer Options:

 This condition is a complication of dacryocystitis.
 Hemophilus influenza is implicated as the causative agent in children.
 This condition may progress to periorbital cellulitis.
 This condition is treated in the same way as a hordeolum.

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Correct Answer:

This condition may progress to periorbital cellulitis.

Educational Objective:

Examine the various etiologies of blepharitis.

Key Point:

Blepharitis is the result of chronic seborrheic dermatitis (> 4-week duration), but it may become acute secondary to infection with Staphylococcus aureus or epidermidis.

Explanation:

The description of the patient’s problem and the Figure display matted, honey-colored crusts on the anterior lid that are most consistent with blepharitis, which may occur alone or in association with staphylococcal blepharitis, seborrheic dermatitis, or meibomian gland dysfunction. Blepharitis is an ulcerative or nonulcerative inflammation of the edges of the eyelid margin involving the hair follicles and glands that open to the surface. It appears on examination as a variable amount of scaling or scurf. The condition is usually a long-term complication of seborrheic dermatitis (> 4-week duration), but it may become acute secondary to infection with S aureus or S epidermidis. In addition, there is a common association with Moraxella angular–associated blepharoconjunctivitis.

Staphylococcal blepharitis presents more commonly in younger patients, with symptoms, such as burning, itching, crusting, and foreign body sensations, more severe in the morning due to the buildup of the crusty material during the night, gradually improving throughout the day. Less commonly, patients may display chronic redness of the eyelid with an associated keratitis or conjunctivitis (15% of cases). In addition, one-third of patients with seborrheic blepharitis will have an evaporative dry eye. Laboratory testing consists of eyelid and conjunctival cultures with susceptibility testing to guide treatment in cases refractory to empiric antibiotic therapy.

In mild cases, treatment is centered on eyelid hygiene and consists of lid scrubs with a nonirritating shampoo containing selenium sulfide, followed by the application of topical corticosteroids, which may be given if reduction of inflammation is warranted. The condition can progress to periorbital cellulitis, in which case more aggressive treatment (oral antibiotics, possible hospital admission, parenteral antibiotics) is warranted.

H influenza is not associated with blepharitis, although it can cause periorbital cellulitis in children. In addition to seborrheic dermatitis, blepharitis is associated with hordeola, rosacea, and dry eyes, but not with dacryocystitis or Crohn disease.

Dacryocystitis is an infection of the lacrimal drainage system that presents with inflammation and swelling below the medial eye, perhaps with purulent drainage from the lacrimal duct. It is most commonly due to a staphylococcal infection, followed by streptococcal infection, and then Haemophilus species as causative agents. It should be treated with warm compresses, an oral broad-spectrum antibiotic, a topical antibiotic, gentle massage of the involved lacrimal duct, and ophthalmic referral.

Reference:

Pflugfelder SC, Karpecki PM, Perez VL. Treatment of blepharitis: recent clinical trials. Ocul Surf. 2014;12(4):273-284.

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