A 65-year-old woman visited the outpatient eye clinic with a complaint of persistent itching. She had developed facial paralysis 6 years prior and accordingly underwent a lateral tarsorrhaphy five years prior. Left eye lateral tarsorrhaphy had been implemented; however, severe left brow ptosis was notable. Bell's phenomenon was strongly positive. In the primary position, there were no signs of eyelid abnormality [Fig. 1]. Complete ophthalmic examination involves assessment of visual acuity, extra-ocular movements, and pupillary movements.[1] However, when the left brow was lifted up, a thick, white, clumpy (cottage-cheese-like) substance with minimal odor was detected [Fig. 2]. C. albicans was confirmed on culture. C. albicans can cause infections that range from superficial skin infections to life-threatening systemic infections.[2,3,4] The patient had no predisposing immune deficiency diseases such as diabetes mellitus. The white colonies of C. albicans were removed and the eyelid skin was found to be intact. There were no signs of fungal invasion. The patient was prescribed topical oxiconazole nitrate 1% cream (twice per day) and terbinafine hydrochloride 250 mg (once per day). The patient was told to keep the eyelid dry. There were no symptoms of cutaneous candidiasis such as itching and no supporting clinical findings in the first week of follow-up.
Figure 1.
Sign of candidiasis observed in the primary position
Figure 2.
Cottage cheese-like substance found when the brow was lifted up
To date, there have been no reports of cutaneous candidiasis of the upper eyelid, neither as a complication of long-term facial paralysis nor in a healthy individual. This case has demonstrated that cutaneous candidiasis in the eyelid can occur even in an individual with a normal immune system as a complication of long-term facial paralysis. Furthermore, this case highlights the value of complete examination of ocular adnexa and the importance of lifting up the brow to check the deep upper lid in every facial paralysis patient.
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Informed consent was taken in accordance with the principles of Declaration of Helsinki.
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Conflicts of interest
There is no conflict of interest.
References
- 1.Rahman I, Sadiq S. Ophthalmic management of facial nerve palsy: A review. Surv Ophthalmol. 2007;52:121–44. doi: 10.1016/j.survophthal.2006.12.009. [DOI] [PubMed] [Google Scholar]
- 2.Mayer FL, Wilson D, Hube B. Candida albicans pathogenicity mechanisms. Virulence. 2013;4:119–28. doi: 10.4161/viru.22913. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Steubesand N, Kiehne K, Brunke G, Pahl R, Reiss K, Herzig KH, et al. The expression of the beta-defensins hBD-2 and hBD-3 is differentially regulated by NF-kappaB and MAPK/AP-1 pathways in an in vitro model of Candida esophagitis. BMC Immunol. 2009;10:36. doi: 10.1186/1471-2172-10-36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Feng Z, Jiang B, Chandra J, Ghannoum M, Nelson S, Weinberg A. Human beta-defensins: Differential activity against candidal species and regulation by Candida albicans. J Dent Res. 2005;84:445–50. doi: 10.1177/154405910508400509. [DOI] [PubMed] [Google Scholar]