Swollen eyelids

Swollen eyelids are oedema, inflammation or a mass of the upper or lower lids, unilateral or bilateral, acute or chronic. Most causes are benign (allergy, stye, blepharitis, chalazion), but infection of the orbit, thyroid eye disease, angioedema and cancers also present with lid swelling.

Anatomy. The orbital septum separates the lids from the orbit. Preseptal cellulitis is limited to the lid; orbital cellulitis involves tissues behind the septum and threatens sight and the brain.

Classification.

• Acute unilateral: stye, preseptal cellulitis, orbital cellulitis, insect bite, dacryocystitis, herpes zoster, trauma, allergic contact dermatitis, angioedema.
• Acute bilateral: allergic and contact reactions, angioedema, viral conjunctivitis, nephrotic and nephritic syndromes, anaphylaxis, infectious mononucleosis, trichinosis.
• Chronic: chalazion, blepharitis, thyroid eye disease, floppy eyelid, dermatochalasis, systemic oedema, tumours, sarcoidosis, lymphoma, amyloid.

Key distinctions. Proptosis, pain on eye movement, restricted movement, reduced vision and fever indicate orbital cellulitis. Periorbital swelling worst in the morning with pallor and frothy urine indicates nephrotic syndrome. Painless, rubbery, bilateral swelling with lid retraction indicates thyroid eye disease. Rapid swelling with itch and urticaria indicates allergy or angioedema.

History.

• Onset (minutes, days, weeks), unilateral or bilateral
• Pain, itch, redness, fever, vision change, double vision, discharge
• Recent trauma, insect bite, dental, sinus or skin infection, upper respiratory infection
• Allergen or drug exposure, cosmetic use, urticaria
• Swelling elsewhere (lips, tongue, throat), breathing or swallowing difficulty, family history of angioedema
• Thyroid symptoms, urinary symptoms (foamy urine, reduced output), heart failure or liver disease, weight change
• Systemic symptoms (night sweats, weight loss), and recent travel

Drug history. ACE inhibitors, angiotensin receptor blockers, NSAIDs and aspirin, penicillins and other antibiotics, contrast agents, topical eye drops and cosmetics, calcium channel blockers (oedema), glitazones, and chemotherapy.

Examination.

• Temperature, pulse, blood pressure, respiratory rate, oxygen saturation
• Airway and tongue (angioedema)
• Visual acuity, pupils (relative afferent defect), colour vision, eye movements (pain, restriction)
• Proptosis (compare), lid position (ptosis, retraction, lag)
• Globe, conjunctiva (chemosis, injection), cornea, fundus (disc swelling), medial canthus
• Sinuses, teeth, skin (rash, vesicles, urticaria), lymph nodes, thyroid
• Heart and lung signs of heart failure, abdomen and legs (oedema), and urine dipstick

Red flags

• Fever with proptosis, painful or restricted eye movements, reduced vision, or relative afferent pupillary defect (orbital cellulitis)
• Lip, tongue or throat swelling, stridor, wheeze or hypotension (angioedema, anaphylaxis)
• Bilateral or unilateral swelling with headache, double vision, cranial nerve palsy or reduced consciousness (cavernous sinus thrombosis)
• Child under 5 years with fever, lid swelling and ill appearance
• Vesicles on the forehead or nose tip (herpes zoster ophthalmicus)
• Periorbital swelling with nephrotic features, hypertension or oliguria
• Painless hard mass, ulceration, lash loss or non-healing lesion (malignancy)
• Diabetes or immunosuppression with black necrotic tissue (mucormycosis)
• Trauma with orbital fracture, or foreign body

Special groups.

• Children: preseptal and orbital cellulitis, nephrotic syndrome, allergic reactions, infantile haemangioma.
• Pregnancy: pre-eclampsia (facial oedema with hypertension), allergic reactions.
• Older adults: dermatochalasis, heart failure, tumours.
• Region specific: onchocerciasis, trypanosomiasis (Romana sign), loiasis (Calabar swelling), cysticercosis and schistosomiasis.

Infective and inflammatory

• Hordeolum (stye), chalazion, blepharitis, preseptal cellulitis, impetigo, erysipelas
• Orbital cellulitis and abscess, cavernous sinus thrombosis, dacryocystitis, dacryoadenitis
• Herpes zoster and herpes simplex, molluscum contagiosum, conjunctivitis (viral, adenoviral, Parinaud)
• Insect and arthropod bites, trauma, post-operative reaction
• Parasitic: trichinosis, loiasis (Calabar swelling), onchocerciasis, trypanosomiasis (Romana sign), cysticercosis, dirofilariasis

Allergic and angioedema

• Allergic and contact dermatitis (cosmetics, drops, latex), urticaria, atopic eyelid eczema
• Angioedema: allergic, ACE inhibitor induced, hereditary (C1 esterase inhibitor deficiency), acquired
• Anaphylaxis, serum sickness

Systemic oedema

• Nephrotic and nephritic syndromes, heart failure, hepatic failure, hypoalbuminaemia, hypothyroidism (myxoedema), pre-eclampsia, superior vena cava obstruction
• Dermatomyositis (heliotrope rash), systemic lupus erythematosus, infectious mononucleosis

Orbital and thyroid

• Thyroid eye disease, idiopathic orbital inflammatory syndrome, IgG4 related disease, sarcoidosis, granulomatosis with polyangiitis, carotid cavernous fistula, orbital varices

Masses and tumours

• Chalazion, cyst, papilloma, haemangioma (infantile), lymphangioma, neurofibroma, dermoid
• Basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma, melanoma, Merkel cell carcinoma, lymphoma, metastasis, orbital tumours (rhabdomyosarcoma, lacrimal gland tumour, optic nerve glioma)

Other

• Dermatochalasis and fat prolapse, blepharochalasis, floppy eyelid, fluid retention from sleep position, drug related oedema, trauma, haematoma (blepharohaematoma, basal skull fracture)

Reasoning. Assess for airway threat first. Then separate preseptal from orbital cellulitis using eye movement, proptosis and vision, and image when in doubt. For chronic or bilateral swelling, test for systemic causes.

First line. Vital signs, airway, visual acuity, pupils, eye movements, proptosis, fundoscopy and urine dipstick (protein, blood).

Targeted tests.

• Full blood count, C reactive protein, ESR, urea, creatinine, electrolytes, albumin, glucose and blood cultures for suspected infection or systemic disease. Urine protein to creatinine ratio, and serum albumin and lipids for nephrotic syndrome.
• CT orbits and sinuses with contrast for suspected orbital cellulitis, abscess, trauma or tumour; MRI with venography for cavernous sinus thrombosis or intracranial extension.
• Thyroid function, thyroid stimulating hormone receptor antibodies, and orbital imaging for thyroid eye disease.
• Complement C4 and C1 esterase inhibitor level and function for recurrent angioedema (C4 low in hereditary angioedema); tryptase after anaphylaxis (within 1 to 2 hours).
• Skin prick tests, patch tests and specific IgE for allergy.
• ANCA, angiotensin converting enzyme, serum IgG4, antinuclear antibody and chest imaging for inflammatory disease.
• Biopsy of any persistent lid lesion, or orbital mass; lymphoma staging when indicated.
• Culture of discharge or aspirate, eosinophil count, blood film for filariae, stool and serology for parasites in endemic or travel related disease.
• B type natriuretic peptide and echocardiogram for suspected heart failure; liver function for hepatic causes.

Limitations. CT may underestimate early orbital involvement. Inflammatory markers may be normal in early cellulitis.

Anaphylaxis and angioedema with airway risk (emergency).

• Intramuscular adrenaline (epinephrine) 0.5 mg (0.5 mL of 1 in 1,000) into the mid anterolateral thigh, repeated every 5 minutes as needed.
• Children: 0.15 mg under 6 years, 0.3 mg for 6 to 12 years, 0.5 mg over 12 years.
• High flow oxygen, IV fluid 500 to 1,000 mL crystalloid bolus.
• Chlorphenamine 10 mg IV or IM (children 1 mg/kg per dose up to 10 mg) and hydrocortisone 200 mg IV for adjunctive treatment (evidence is limited).
• Nebulised salbutamol for bronchospasm.
• Early airway assessment and intubation by experts.

Observe for at least 6 to 12 hours. Adrenaline autoinjector, allergy referral and written action plan on discharge.

ACE inhibitor induced angioedema. Stop the drug and avoid angiotensin converting enzyme inhibitors in future (angiotensin receptor blockers with caution). Give airway support, and adrenaline for airway threat. Use icatibant 30 mg subcutaneously (specialist) when severe.

Hereditary angioedema. Acute attack: C1 esterase inhibitor concentrate 20 units/kg IV, or icatibant 30 mg subcutaneously (repeat after 6 hours if needed, maximum 3 doses in 24 hours). No adrenaline or antihistamine response is expected. Protect the airway. Long term prophylaxis by immunology. Avoid ACE inhibitors and oestrogens.

Orbital cellulitis and abscess (admit).

• Ceftriaxone 2 g IV every 12 hours (children 50 mg/kg every 12 hours, maximum 2 g) plus metronidazole 500 mg IV every 8 hours (children 7.5 mg/kg every 8 hours).
• Add vancomycin when meticillin resistant Staphylococcus aureus is possible: 25 to 30 mg/kg IV loading dose, maximum 3 g, then 15 to 20 mg/kg every 8 to 12 hours adjusted to creatinine clearance and levels.
• Urgent CT, ophthalmology and ENT.
• Surgical drainage for abscess, falling vision, or failure to improve in 24 to 48 hours.
• Neurosurgical review for intracranial extension.

Duration 2 to 3 weeks, switching to oral amoxicillin with clavulanic acid 625 mg three times daily when improved.

Cavernous sinus thrombosis. IV ceftriaxone 2 g every 12 hours plus metronidazole 500 mg every 8 hours. Anticoagulation is a specialist decision (enoxaparin 1 mg/kg subcutaneously every 12 hours, adjusted when creatinine clearance is under 30 mL/min). Arrange urgent imaging and neurosurgical and ENT care.

Preseptal cellulitis.

• Amoxicillin with clavulanic acid 625 mg orally three times daily for 7 days (children 40 to 50 mg/kg of the amoxicillin component daily in 3 divided doses).
• Review at 24 to 48 hours.
• Penicillin allergy: clarithromycin 500 mg orally twice daily (children 7.5 mg/kg twice daily) for 7 days, or doxycycline 100 mg twice daily for adults.
• Admit when systemic illness, age under 1 year, no improvement or any orbital sign.

Hordeolum (stye) and chalazion.

• Warm compresses for 5 to 10 minutes 3 to 4 times daily, and lid hygiene.
• Remove the offending lash for external stye.
• Antibiotic only for cellulitis (amoxicillin with clavulanic acid 625 mg orally three times daily for 7 days).
• Incision and curettage of persistent chalazion after 4 to 6 weeks, or steroid injection (triamcinolone 10 mg/mL, 0.1 to 0.2 mL) by ophthalmology.
• Biopsy of recurrent chalazion in the same site (sebaceous carcinoma).

Herpes zoster ophthalmicus. Valaciclovir 1 g orally three times daily for 7 days. Adjust for kidney function: creatinine clearance 30 to 49 mL/min, 1 g every 12 hours; 15 to 29 mL/min, 1 g daily; under 15 mL/min, 500 mg daily. Give analgesia and arrange same day ophthalmology review.

Allergic and contact lid swelling. Remove the allergen and apply cold compresses. Apply hydrocortisone 1 percent ointment thinly to lid skin twice daily for up to 7 days (avoid prolonged use, which causes skin thinning and glaucoma risk). Give an oral antihistamine (cetirizine 10 mg orally once daily; 5 mg in renal impairment). Give oral prednisolone 30 to 40 mg daily for 3 to 5 days for severe reactions.

Thyroid eye disease.

• Smoking cessation, euthyroid state, lubricants, head elevation at night.
• Mild disease: selenium 100 micrograms orally twice daily for 6 months.
• Moderate to severe or sight threatening disease: methylprednisolone 500 mg IV weekly for 6 weeks then 250 mg weekly for 6 weeks (cumulative dose under 8 g, with liver function monitoring).
• Orbital radiotherapy, decompression surgery or teprotumumab by specialists.
• Ophthalmology and endocrinology care.

Systemic oedema. Treat the cause:

• Nephrotic syndrome: prednisolone 1 mg/kg daily in children, 1 mg/kg daily to a maximum of 80 mg in adults, with renal referral.
• Heart failure: furosemide 40 mg orally daily, adjusted, with monitoring of potassium and renal function.
• Hypothyroidism: levothyroxine 1.6 micrograms/kg orally daily; start at 25 to 50 micrograms in older adults and heart disease.
• Pre-eclampsia: urgent obstetric care; labetalol 200 mg orally twice daily or nifedipine modified release 10 to 20 mg twice daily; magnesium sulphate 4 g IV over 5 to 15 minutes then 1 g/hour for seizure prophylaxis in severe disease.

Inflammatory and tumour causes.

• Idiopathic orbital inflammatory syndrome or IgG4 related disease: prednisolone 40 to 60 mg orally daily after exclusion of infection and lymphoma, with specialist care.
• Skin cancers and lymphoma: urgent biopsy, multidisciplinary oncology care (surgery, radiotherapy or systemic therapy).
• Infantile haemangioma threatening vision: propranolol 1 to 3 mg/kg daily in 2 to 3 divided doses (specialist, with cardiac and glucose monitoring) or timolol 0.5 percent gel.

Parasitic causes.

• Loiasis: diethylcarbamazine by specialists (after assessment of microfilarial load).
• Onchocerciasis: ivermectin 150 micrograms/kg orally as a single dose, repeated every 6 to 12 months (not with heavy loiasis without specialist advice).
• Trichinosis: albendazole 400 mg orally twice daily for 8 to 14 days with prednisolone for severe disease.
• Cysticercosis: specialist care.

Mucormycosis. Immediate ENT, ophthalmology and infectious disease referral. Give liposomal amphotericin B 5 mg/kg IV daily (up to 10 mg/kg with CNS disease), with glycaemic control and urgent surgical debridement.

Trauma. Image for orbital fracture and foreign body. Apply cold compresses and advise nasal precautions. Give prophylactic oral antibiotics for sinus involvement (amoxicillin with clavulanic acid 625 mg three times daily for 5 to 7 days). Arrange urgent surgery for entrapment (especially in children), retrobulbar haemorrhage (emergency lateral canthotomy and cantholysis) or open injury. Give tetanus prophylaxis.

Dermatochalasis and cosmetic swelling. Reassurance and surgery by oculoplastic surgeons when functional visual field loss.

Monitoring. Review at 24 to 48 hours for cellulitis, visual acuity and eye movement at each review, and weekly thyroid eye disease activity scores during active treatment.

Referral and escalation. Immediate emergency care for airway threat, orbital cellulitis, or cavernous sinus thrombosis. Same day ophthalmology for visual loss, proptosis, or herpes zoster ophthalmicus. Nephrology, cardiology or obstetrics for systemic oedema. Endocrinology for thyroid eye disease. Oncology for tumour.

Admission criteria. Anaphylaxis or angioedema with airway risk, orbital cellulitis, cavernous sinus thrombosis, preseptal cellulitis with systemic illness or in infants, retrobulbar haemorrhage, heart failure, nephrotic syndrome with complications, severe pre-eclampsia, or mucormycosis.

Discharge and safety netting. Return for spreading redness, fever, proptosis, double vision, reduced vision, pain on eye movement, swelling of the lips or tongue, difficulty breathing or swallowing, severe headache, or no improvement in 48 hours.