Photo Quiz: Persistent eyelash debris in a 10-year-old female

PHOTO QUIZ FIG 1 (A) Patient's left eye showing waxy, cylindrical, dandruff-like material encasing the base of several lashes of the upper eyelid.(B) Wet-mount (magnification, 20×) of an epilated eyelash from the patient showing keratinous debris (red arrows) and a single adult, cylindrical, microorganism (black arrow) consisting of an anterior gnathosoma (G), podosoma (P) containing four pairs of legs, and posterior opisthosoma (O).A 10-year-old female with severe obesity and medically controlled diabetes mellitus was evaluated by an ophthalmologist for itchy eyes and bilateral upper eyelid dandruff of 1-month duration not relieved by over-the-counter eye drops.Her parents often reported seeing eyelashes on her cheeks and stated that both shed and attached eyelashes had a thick, whitish base.The patient was otherwise healthy and up to date on all vaccinations.Her vital signs were within normal limits, and her body mass index was 41.6 (>99th percentile).Laboratory studies were significant only for a hemoglobin A1c of 5.8 (reference, <6%).Physical examination was significant for the presence of white-togray, waxy, cylindrical, flaky material primarily coating the base of individual lashes of both upper eyelids (Fig. 1A).Epilated eyelashes were sent to the laboratory for evalua tion.A wet mount preparation was evaluated by a pathologist, who noted the presence of keratinous debris and microorganisms associated with the hair shaft (Fig. 1B).