History

A 30 year old man presented for consultation to an urban Eye Center in Mumbai, India with complaints of itching in the right upper lid (RUL) since one month. Previous ocular history: None. Past medical history: None

Examination

Visual acuity OD: 20/20 OS: 20/20
Pupils: Normal OU
Motility: Full OU
Tonometry: Normal OU
Slit lamp examination of the anterior segment: Normal OU
Fundus examination: Normal OU
Eyelid exam: The RUL revealed multiple cigar shaped foreign bodies locates at the base to the eyelashes along with bleeding and crusting of the eyelid margin.

Differential Diagnosis

1. Ulcerative Blepharitis

2. Demodicosis

3. Hordeolum

Diagnosis

The signs of typical blepharoconjunctivitis, blood stained thickened discharge on the eyelid margins, and the presence of nits on the eyelashes and adult parasites in their roots are distinctive features of this entity. (see Figure) It may be confused with other forms of blepharitis, unless one looks for the above signs. Diagnosis was confirmed by microscopic examination of the louse. Morphologically, P pubis may be distinguished from pediculus by its distinctive crablike appearance.

Adult lice infest hairs of the scalp, axilla, chest, pubic, rarely, eye brows and eye lashes. Infestation of lice on eye brows or eye lashes is most commonly caused by Phthirus pubis, rarely by Pediculus capitis,and never by Pediculus corporis. The transference to the eye is sup posed to achieve through the hand contact to the genital region.

The pubic louse can be identified as a 2 mm long, grayish-white in sect (smaller than a body louse) with a distinctively crab like appearance. They lay seven to ten eggs (nits) per day. The incubation period is usually between 5 days and several weeks. The tiny, translucent oval eggs at the bases of the hair shafts and often confused with the crusty flakes of seborrheic blepharitis. Blepharitis with marked conjunctival in flammation, preauricular lymphadenopathy and secondary infection at the site of lice bite may also occur. Marginal keratitis is rare.

Infestation of the eyelids is treated with twice daily applications of petrolatum for seven to 10 days. Alternative treatments include anticholinesterase eye ointments, yellow oxide of mercury, or 20 % fluorescein. The simplest technique for the treatment of eyelid lice is direct removal of the lice and nits with fine forceps. Cryotherapy may provide a fast cure. Application of 1% gamma-benzene hexachloride cream, permethrin ointment and oral Ivermectin are other options. As one third of patients with pubic lice infestation may have other sexually transmitted diseases, they should be examined for these infections. Clothing and bed linen must be washed and heat dried after each treatment.