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Blepharitis represents a frequent inflammatory condition of the lids including the lid margin, which can be apparent in adults and children. Chronic blepharitis is therapeutically challenging. According to the anatomic localization, blepharitis can be graded in anterior and posterior forms. Blepharitis can lead to severe symptoms and complications, mainly dry eye disease, corneal complications and defective lid position. The pathogenesis of chronic blepharitis is not fully understood so far, however, multifactorial disease proceedings are supposed, which include systemic diseases (mainly dermatological disorders), habitual bacteria and infections. In all these processes inflammatory changes are the common final path.Therapeutic strategies include topical and systemic therapies, however evidence levels are generally low and patients are often resistant to therapy. Basic therapeutic measures are warm compresses, lid hygiene and lubricants. Topical anti-inflammatory drugs comprise corticosteroids and ciclosporin A. Topical and systemic antibiotics are commonly used. Systemic intake of omega-3 fatty acids is often recommended due to its anti-inflammatory potential., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein. Erklärung zu nichtfinanziellen Interessen Mitgliedschaften: Deutsche Ophthalmologische Gesellschaft (DOG), Association for Research in Vision and Ophthalmology (ARVO)., (Thieme. All rights reserved.)

Ocular rosacea in children is a rare but often underdiagnosed condition. It is typically associated with chronic blepharoconjunctivitis, chalazia, corneal opacity and corneal neovascularization. The recommended treatment consists of topical (eyelid hygiene, steroids, cyclosporin, lubricants) and systemic (antibiotics e.g. erythromycin) measures. This case series of 8 children demonstrates the efficacy of local 1.5% azithromycin treatment together with eyelid hygiene in pediatric ocular rosacea. A further advantage of this topical treatment is that the required application of only twice daily for 3 days followed by 7 days without treatment is convenient and improves adherence to treatment.

Patients with atopic dermatitis frequently complain of ocular symptoms. The general dermatitis can directly affect the periocular skin and patients often present with chronic atopic blepharokeratoconjunctivitis. Early diagnosis of the characteristic ophthalmological alterations, such as blepharitis, allergic conjunctivitis, keratoconjunctivitis sicca, conjunctival scarring with formation of symblepharon and lid malpositioning, filiform keratitis, corneal plaques, (persistent) epithelial defects, corneal ulcers and keratoconus as well as appropriate stage-adapted treatment, including lid hygiene with preservative-free lubricants, topical and sometimes systemic anti-inflammatory therapy and surgical treatment are important for patients to prevent long-term damage of the ocular surface leading to severe visual impairment.

Atopic dermatitis (AD) is a systemic inflammatory disease, which is characterized by pronounced eczema and pruritus. In addition to the involvement of the entire integument, the periocular lid skin and the surface of the eye are frequently involved. Ocular involvement may occur solely without dermatitis of facial or body skin. Pathophysiologically, besides a dysregulated immune response, genetic changes can occur in various dermal structural proteins which will lead to a disturbed skin barrier. Furthermore, there is a regular colonization with bacterial pathogens and an increased susceptibility for viral skin infections. The lid margin reveals a loss of Meibomian glands whereas the conjunctiva shows reduced goblet cells. Consecutively, eye surface defects and recurrent conjunctival and corneal defects can be found. Increased mechanical manipulation in atopia-associated pruritus is seen as a cause of increased comorbidity with keratoconus. In addition, individual cases are reported of various malignomas of the eye surface, which are present in patients with AD. Understanding of the pathophysiological connections is essential for the correct diagnosis and therapy of this clinically very complex disease picture.

Peri-ocular necrotising fasciitis is a very rare ophthalmological clinical picture and is potentially fatal. This disease is caused by bacterial infection of the fasciae, which rapidly spreads. The present article reports a typical case of the disease and gives an overview of the typical clinical signs and symptoms of peri-ocular necrotising fasciitis., (Georg Thieme Verlag KG Stuttgart · New York.)

Background Wounds of the eyelid can usually be cured with common surgical measures and the use of local antibiotics. Here we present two cases to demonstrate that biological debridement and negative pressure vacuum therapy (NPWT), two second line therapies, are effective and possibly superior alternatives to conventional, antibiotic-based approaches. Methodology and Result A persistent infectious wound of the upper eyelid after surgical debridement of necrotising fasciitis and an upper eyelid abscess with multiple purulent entry points, which was refractory to a five-week antibiotic regimen, were treated with biological debridement and NPWT. The combination of these two therapies leads to an optimal outcome. Conclusion Our cases demonstrate that, in ophthalmology, uncommon methods such as biological debridement and NPWT are quite practicable and are valuable therapeutic options., (Georg Thieme Verlag KG Stuttgart · New York.)

The goal of the treatment of chronic blepharitis lies in the reduction of inflammation, which can be achieved by warming, mechanical, and immunomodulatory measures as well as acaricide medication in cases with pathogenetically relevant demodicosis.

Aim: Meibomian gland dysfunction/blepharitis is usually a harmless inflammatory process of the lid margin. However, it can be the first sign of a malignant lesion. Patients/Results: Clinical and histological findings are illustrated for 8 patients with changes in the lid margin and with the differential diagnosis of blepharitis., Conclusion: Tumours of the lid margin can mimic blepharitis or induce meibomian gland dysfunction. Conversely, blepharitis can present in a nodular form, which is highly indicative of a neoplasm. In these cases, surgical excision with ophthalmopathological evaluation of the tissue is mandatory, in order to reach the correct diagnosis and to treat the patient appropriately., (Georg Thieme Verlag KG Stuttgart · New York.)

Case Report: A 16-year-old female patient initially presented with bilateral swelling and redness of the eyelids already existing for the duration of two days. The symptoms had started after the patient dyed her eyelashes and eyebrows with henna., Therapy: Systemic antihistamine and glucocorticoid therapy led to no visible improvement. An intravenous antibiotic treatment was started which resolved the symptoms entirely., Conclusion: The diagnosis of an allergic contact dermatitis with a secondary bacterial infection was made.

Background: Blepharitis due to Meibom gland dysfunction (MGD) is presumed to be one of the main reasons for dry eye symptoms which occur in up to 50% of contact lens users. Thus, MGD presumably plays an important role in dry eye in contact lens wearers. In the present prospective, randomized and double blind trial the efficacy of two established treatment options for MGD and blepharitis was evaluated in symptomatic contact lens wearers., Methods: In this prospective, randomized 2-centre trial 53 symptomatic contact lens wearers suffering from blepharitis were included. Patients were randomly selected for two treatment groups: group A performed lid margin hygiene using the commonly recommended mild baby shampoo (Bübchen Kinder Shampoo-extra augenmild, Bübchen Werk Ewald Hermes Pharmazeutische Fabrik GmbH, Soest, Germany) and group B performed lid margin hygiene using a phospholipid-liposome solution specially designed for lid hygiene (Blepha Cura, Optima, Moosburg/Wang, Germany), each for 4 weeks. Before as well as 4 weeks after initiation of this study the following tests were performed: standardized subjective assessment using the ocular surface disease index, non-invasive break-up time (NIBUT) and objective evaluation of lid-parallel conjunctival folds (LIPCOF) and further lid margin criteria by double blinded evaluation of slit lamp photographs., Results: Of the 53 symptomatic contact lens wearers suffering from blepharitis 21 (39,6%) were randomly selected for treatment group A and 32 (60.4%) for group B. In both treatment groups there was objective and subjective improvement of symptoms of dry eye in contact lens wearers. Interestingly, there was a significantly greater improvement, subjective as well as objective, in treatment group B which used the phospholipidliposome solution for lid margin hygiene compared to group A using baby shampoo., Conclusions: Although both therapies improved symptoms of dry eye due to blepharitis in symptomatic contact lens wearers, patients using phospholipid-liposomal solution for lid margin hygiene demonstrated a significantly greater clinical benefit from the therapy. Thus, clinical practice recommending just baby shampoo for lid margin hygiene should be re-considered, as phospholipid-liposomal solution for lid margin hygiene appears to yield greater and faster clinical benefits for symptomatic contact lens wearers suffering from dry eye symptoms.

A 9-year-old boy presented with bilateral chronic thickening of the upper and lower eyelid margins with bead-like papules. The voice was hoarse due to a previously diagnosed thickening of the vocal cords. There was a history of recurrent abscesses of the parotid gland and of attention deficit hyperactivity disorder (ADHD).The eyelid changes were recognized as monoliform blepharitis and the diagnosis of lipoid proteinosis (Urbach-Wiethe disease) was confirmed by eyelid biopsy. The diagnosis of this systemic disease explained the other signs and symptoms of the patient.

Numerous diseases affect both skin and eyes due to similar ontogenetic origin. The eye is the second most common site of melanoma after the skin. The eyelids are predisposed for development of toxic and allergic dermatitis as the skin in this region is four times thinner than the other facial skin. The differential diagnosis must include atopic and seborrhoeic eyelid dermatitis. Atopic and vernal keratoconjunctivitis are associated with atopic eczema. Various immunobullous disorders involve the conjunctiva with varying severity. Side effects of dermatologic treatments with glucocorticoids, antimalarials, psoralens, retinoids, or tetracyclines may involve the eye.

An 8-year-old boy presented with a 6-week history of a rapidly progressive erythematous swelling of the right upper eyelid. Ultrasonography and magnetic resonance imaging revealed a subcutaneous nodular mass of the right upper eyelid medially with extension into the anterior orbit. The clinical differential diagnosis included rhabdomyosarcoma. A transcutaneous excisional biopsy was performed, and histopathologic examination confirmed the diagnosis of nodular fasciitis. Five years after surgery, there is no evidence of local recurrence, and the result is aesthetically satisfactory.

We present a case of a 53-year-old female patient with chronic blepharitis and conjunctival overgrowth of the cornea. Histologically the conjunctival overgrowth contained foreign body granulomas around calcification focuses. This could have been promoted by the application of phosphate-containing eye drops and the presence of chemokines like TNF-alpha, which occur in chronic blepharitis. Thus, we recommend the application of phosphate-free eye drops in patients with chronic blepharitis.

Chronic blepharitis is one of the most common diseases of the eyelids, but surprisingly, it is not often recognized. Frequently, a skin disease such as seborrheic dermatitis, atopic dermatitis, or acne rosacea is the underlying cause of chronic blepharitis. Bacterial pathological lipase, cholesterylesterase production, and bacterial lipopolysaccharides are pathogenetically relevant. Only rarely do genuine bacterial infections play a role. Collarettes occur at the base of the eye lashes, and the Meibomian glands show either abundant fluid secretion or inspissated secretion with obstruction of the orifices. Chronic blepharitis can include sequelae including dry eye and corneal and lid contour changes. The basic treatment comprises attendance of the underlying dermatological disease and lid hygiene. In addition, preservative-free tear film substitutes, antibiotics, immunomodulatory agents, or even surgical intervention may become necessary.

Lidedema can be a common symptom of diseases of the orbital part of the face. One can differentiate lidedema in two groups, those that are related to an inflammation and those that are not related to an inflammation. Lidedema of the eyelid can also be secondary to a systemic disease. There is also another group that is common in the ageing population that consists of blepharochalasis and dermatochalasis where the skin becomes loose with the years and forms redundant folds.

Blepharitis is characterized by a great variety of clinical manifestations, which often include alterations of the ocular surface. This as well as its tendency to be therapy-resistant and recurrent explains why blepharitis marks a challenge for all ophthalmologists. Occasionally dermatologic diseases represent one of the causes of the disease, thus calling for an interdisciplinary approach. The present article describes the state of the art with regard to pathogenesis and therapy of blepharitis.

In the doctor's office, seasonal and non-seasonal conjunctivitis must be differentiated from more serious conditions. These include vernal conjunctivitis which, when chronic, represents a risk for corneal complications. In atopic keratoconjunctivitis, too, which manifests in every fourth patient with atopic dermatitis, the patient's vision is in danger. Furthermore, wearers of contact lenses may develop characteristic conjunctival changes or a contact allergy triggered by lens cleansing fluid. When the diagnosis has been established, treatment with local or systemic antihistaminics, H1 blockers or mast cell stabilizers can be initiated. In contrast, the indication for glucocorticoids should be established only by an ophthalmogist.

Background: Periorbital allergic contact dermatitis is a rare disease and the main differential diagnoses are atopic and seborrhoeic dermatitis. The diagnosis is based on clinical appearance, patient history and patch testing. Current systematic overviews on contact allergens involved are lacking and with changes in medical preparations, new relevant antigens may emerge., Patients and Methods: Based on the systematic data of the information network of dermatological clinics (IVDK), patch test reactions in 48,969 patients tested between 1996 and 2000 were evaluated. A total of 763 patients suffered from periorbital dermatitis which was suspected to be due to the use of topical medication., Results: The most common epidermal sensitizations in the general population were observed against nickel and fragrances. In the periorbital dermatitis group, sensitization against local anaesthetics and antibiotics was more frequent than in the general population., Conclusions: In three patients, oxybuprocain was identified as the causative agent, which has not yet been recognized as a common allergen.

Background: The eye and its adnexa are frequently involved in sarcoidosis. Keratoconjunctivitis sicca is a typical manifestation that is believed to result from aqueous-layer deficiency in context with lacrimal gland disease. In this study we determined which layer of the tear-film might be involved., Patients and Methods: Fifty-six patients with clinically and histologically proven sarcoidosis were prospectively analysed for symptoms of dry eye, visual acuity, signs of blepharitis, Schirmer II test, rose bengal test, fluorescein staining, break-up time (BUT), and impression cytology (IPC). Deficiencies of the lipid, water and mucin layers were differentiated. The observations were compared with those from a control group of patients with symptoms of "dry eye" (n = 56)., Results: All patients in the control group, but only 20 sarcoidosis patients had dry eye symptoms. The BUT in the control group (7.2 +/- 5.4; mean +/- SEM) was shorter (p < 0.02) than in sarcoidosis patients (8.9 +/- 4.5; mean +/- SEM). Compared with the sarcoidosis patients, conjunctivitis occurred more frequently in the control group (p < 0.01). Rose bengal staining was positive in 18 sarcoidosis patients, and in 35 patients of the control group (p < 0.01). Signs of blepharitis, the results of Schirmer test, fluorescein staining and IPC, and the frequent incidence of deficiencies of aqueous layer, lipid layer and combined deficiencies of two or more layers did not differ significantly between the two groups. Deficiencies of the mucin layer were detected in 43 sarcoidosis patients, and in 51 patients in the control group (p < 0.05)., Conclusions: Tear-film deficiencies are common in sarcoidosis patients, even when clinical symptoms are absent. Observations herein suggest that patients with sarcoidosis may not only suffer from deficiencies of the aqueous layer, but also of the mucin and lipid layers.

Background: Ocular symptoms occur in approximately 10% of patients with psoriasis vulgaris., Patient: We report the clinical course of a 35-year-old male patient with obstructive meibomian gland dysfunction, keratoconjunctivitis and reduced reflex secretion of both eyes. Psoriasis vulgaris and hypothalamic hypogonadism were also present. Genetic testing (cytogenetic and DNA analysis) was performed because of additional facial dysmorphia, brachydactylia and obesity. No chromosomal anomaly was found and no genetic syndrome has yet been diagnosed. The therapeutic regimen included preservative-free artificial tears, occlusion of the puncta and a systemic dose of doxycycline. Dermatological symptoms were treated topically and the hypogonadism was treated with intramuscular injections of testosterone., Conclusion: Lacrimal and meibomian glands are influenced by androgens. Therefore hormonal dysfunction can also have contributed to the blepharokeratoconjunctivitis in this patient.

Unlabelled: Autoaggressive syndromes as causes of diseases underlying chronic blepharitis and keratoconjunctivitis that are refractory to treatment are often difficult to recognize., Patients: Three female patients (age 21, 25, 41 years) and one male patient (age 42 years) had suffered from a right-(4x) or left-(1x) handed treatment-refractory blepharokeratoconjunctivitis for 1, 2, 11 and 30 months prior to admission. In each case more than 5 ophthalmologists and 2-6 eye hospitals had been consulted, and extraocular surgery had been performed 1-4 times., Results: Patients presented with a visual acuity of 0.3 p (1x), 0.1 (1x), FC (1x), HM (1x). In three patients contact eczema of the facial skin and lids and a corneal pannus were observed; in two patients we saw purulent pseudomembranous and in two patients chronic cicatrizing keratoconjunctivitis. Conjunctival smears grew P. aeruginosa, and S. aureus; impression cytology showed infiltration with neutrophils and epithelial keratinization; histopathology indicated chronic inflammatory, partly purulent subepithelial and stromal conjunctival infiltrate with hyper- and parakeratosis fibrous strands and epithelial cell loss; the lower lids showed parakeratosis, focal necrosis, intercellular edema and a lymphohistiocytic round-cell infiltrate. Furthermore, multiple allergies to antibiotics and preservatives (4x), lacerations of the arms and legs (2x) and an irritative-toxic dermatitis (1x) were substantiated. In the patients who agreed to a psychiatric consultation, somatized-agitated longing for care combined with a dependent and infantile personality (1x) and reactive depression (2x) were verified., Conclusions: In patients suffering from treatment-refractory unilateral chronic blepharokeratoconjunctivitis correlated with the hand, one must take into consideration the fact that other factors may be involved: possible exacerbation prior to examinations; multiple inpatient diagnostic and surgical procedures in different locations; histopathological mixed inflammatory patterns; and psychiatric syndromes.

Background: Staphylococci represent an important source of external infections of the eye. In addition to acute staphylococcal conjunctivitis a spectrum of subacute or chronic disease may be found. According to Valenton und Okumoto, with this staphylococci-associated blepharo-kerato-conjunctivitis in culture-positive cases S. aureus is found in 31% and S. epidermidis in 69% of smears. Microbiallergic and toxic mechanisms are the underlying etiology., Patients: We report on a series of 38 patients with "red eye" that were seen between 1992 and 1994 in the external disease clinic at the Department of Ophthalmology, University of Heidelberg., Results: There were 17 female and 21 male patients. The mean age was 53 +/- 20 years. The patient's complaints included recurrent red eyes with discomfort and pain. Clinically, a squamous blepharitis (63%) and conjunctivitis (87%) were present. Upon biomicroscopic evaluation, a corneal involvement could be found in 80% of cases. In 66% of cases conjunctival swabs were positive for staphylococci., Discussion: The blepharitis may be squamous or ulcerative. The underlying cause is a dermal irritation by staphylococcal toxins. As early as 1937, Thygeson and Allan postulated a toxin-induced skin irritation by a "dermonecrotic factor." In chronic cases a papillary conjunctivitis caused by a toxin reaction can be observed. Histologically, no lymph follicles or eosinophils are present. Several types of keratitis and corneal involvement are found. An epithelial keratitis is caused by toxic mechanisms. Marginal infiltrates and ulcers indicate an antigen-antibody reaction. Phlyctenulae indicate a delayed immune reaction (Gell and Coombs type IV). Complications include vascular pannus, corneal scarring, and rarely corneal melting and ulcers. Therapy depends on the severity of the inflammation and the underlying pathomechanism. This includes reduction of toxin-producing organisms by hygiene of the lid margins and application of topical disinfectants and antibiotics. With immunological phenomena topical steroids are required.

Unlabelled: Demodex folliculorum has been demonstrated with an elevated frequency in patients with blepharitis, and is thought to cause therapy-resistant blepharitis. This paper presents the germ spectrum of patients with blepharitis and demodex and discusses the efficiency of a specific therapy., Methods: In all, 3152 cilia from 139 patients with blepharitis (38% blepharitis, 44% blepharoconjunctivitis, others) and 108 persons with quiet eyes were examined for demodex. Smears n = 125, from the conjunctive of symptomatic patients were investigated for bacteria, 3 weeks of therapy with mercury ointment, 2%: Lindan, cortisone (prednisolone, dexamethasone, hydrocortisone, fluorometholone) or antibiotics after antibiogram (gentamicin, kanamicin, neomicin, erythromicin, ofloxacin, polymyxin-B, colistin) followed in all Demodex-positive blepharitis patients (n = 41)., Results: Demodex was found in 52% (62/139) of patients with chronic blepharitis, as against 20% (3/15) of those with acute blepharitis (statistically significant difference, chi 2-test, alpha = 2.5%) and in 29% of quiet eyes (statistically significantly less, alpha = 2.5%, chi 2-test). Gram-positive cocci were isolated from 79% of 57 Demodex-positive patients with blepharitis and 72% of 68 Demodex-negative patients anaerobes in 39% and 37%, gram-negative rods in 11% and 3% (statistically significant difference for gram-negative rods, alpha = 5%, chi 2-test). Of the patients with Demodex, 25% apparently had no more parasites after mercury ointment, 2% (n = 8) and lindan (n = 5) and 15% after cortisone and antibiotics (n = 13). (The best and statistically very significant results (alpha = 1%) were those obtained with mercury ointment, 2%, and lindan: t-test for connected spot checks)., Conclusions: Gram-positive and gram-negative bacteria grew more often in patients with Demodex. Demodex seems to be a mediator of chronic blepharitis; we recommend that mites be sought in cilia of chronic blepharitis patients. Mercury ointment, 2% and lindan proved efficient for specific therapy, the main problem being the laborious application and toxicity.

Unlabelled: This study examines the prevalence of coagulase-negative Staphylococcus species in normal and mildly inflamed conjunctiva, their sensitivity to antibiotics, and their relationship to the remaining flora., Patients and Methods: In 99 patients including 9 HIV-positives in an early stage of the infection, 100 conjunctival swabs were taken and microbiologically investigated for bacteria and fungi. Thirty-four were from healthy eyes. 40 were from patients with chronic (n = 28) and unspecific (n = 12) conjunctivitis, 17 were from patients with a variety of outer inflammatory ocular conditions, and 9 were from the HIV group from uninfected (n = 6) and infected (n = 3) conjunctivae. Samples from each patient were collected with three moistened cotton swabs and directly inoculated onto five different agars, followed by immersion into three specific culture broths. Staphylococci were identified species-wise, the other microorganisms genus-wise. Sensitivity to a broad spectrum of antibiotics was determined by agar diffusion tests., Outcome: Staphylococci were found in 89%, which was the highest prevalence genus-wise. Of those, coagulase-negative species accounted for 86%, while coagulase-positive Staphylococcus aureus was isolated in 12% of all swabs. In the 86 smears positive for coagulase-negative staphylococci, 151 different strains were isolated. In these strains, resistance to the 13 tested antibiotics varied from 0% for vancomycin to 66% for penicillin. Strains which were isolated from patients with chronic conjunctivitis showed a greater range of resistance than those from normal flora, with significant levels for ciprofloxacin, gentamycin and kanamycin (Mann-Whitney) U-test: P < 0.05). All except six strains of staphylococci were identified strains represented ten species, of which Staphylococcus epidermidis was most prevalent (74%), but only made up 70% of all isolated strains of the coagulase-negative staphylococci. Staphylococcus aureus and gram-negative bacteria were found significantly more commonly in patients which chronic conjunctivitis than in healthy eyes, while coagulase-negative species of the Micrococcaceae family were significantly more prevalent in the healthy than in the chronically inflamed conjunctiva (chi-square: P < 0.05)., Conclusion: The conjunctiva can simultaneously host several stems of coagulase-negative staphylococci, which differ in regard to species and resistance to antibiotics. This variety might indicate a microbiological balance of the conjunctiva and be reduced in chronic inflammatory conditions. In patients with chronic conjunctivitis the risk for multiresistant coagulase-negative staphylococci is increased.

Patient and Methods: Over a period of one year a 33-year-old married housewife, mother of two healthy children, complained of an initially recurrent, in the last 6 months persisting conjunctivitis, upper and lower lid edema, dacryorrhea and photophobia concerning the left eye. Neither topical derivates of cromoglycin acid, antibiotics nor steroids brought relief. Half a year ago the patient had noticed a "little nodule" of the lateral upper eyelid without tendency to grow. The visual acuity was 0.8 due to a punctate superficial keratopathy. In addition a marked follicular conjunctivitis was present. Our examination revealed a little whitish-rosy tumor with elevated edges and a central crater at the lateral margin of the upper lid. The right eye was completely normal. The tumor was totally excised preserving the lid margin. Our histopathological diagnosis was "molluscum contagiosum". Four weeks after surgery the keratoconjunctivitis had subsided without further medication., Conclusion: In persisting unilateral conjunctivitis without amelioration after any topical therapy the eyelids should be checked carefully for a tumor to be excised. In older patients a sebaceous gland carcinoma must be ruled out. Considering the patient's personal history a chlamydial infection should be kept in mind as a differential diagnosis.

Among the author's patients a number of cases were identified with quite clear symptoms of atopic keratoconjunctivitis, and a photographic documentation was made. All of these patients had a history of allergy and a hereditary taint. In cooperation with dermatologists neurodermitis constitutionalis was diagnosed, and verified by determining the serum IgE concentration and the allergic specific antibody. The patients underwent conservative treatment with sodium cromoglycate, steroids and vasoconstrictors. In one case the authors used cryocoagulation with a successful result for intensive hyperplastic conjunctivitis.

Isolated herpes simplex affecting the lid margin can be distinguished from herpes simplex involving the entire eyelid by characteristic features. The typical intermarginal form of herpes-simplex-blepharitis presents itself as an erosion of about 3 mm in length which may be well discerned in detail after fluorescein staining. The skin adjecent to the lesion may also exhibit superficial ulceration, possibly being covered by crusts. The affected portion of the lid shows localized and moderate swelling as well as pain upon pressure. Injection of the bulbar conjunctiva will characteristically be noted mainly in the area opposing the lid lesion. The regional lymph nodes are enlarged, and possibly tender upon palpation. Local medication with anti-viral ophthalmic ointment is effective within a few days.