What are the causes and management of chemosis?

Causes and Management of Chemosis

Chemosis is primarily caused by fluid accumulation in the subconjunctival space due to inflammation, venous congestion, or lymphatic dysfunction, and management should follow a stepwise approach starting with lubrication and progressing to anti-inflammatory medications, with surgery reserved for refractory cases.

Causes of Chemosis

Anatomical/Mechanical Causes

• Post-surgical complications: Common after blepharoplasty (11.5% incidence), especially lower lid procedures 1
• Orbital processes: Venous congestion from orbital or cavernous sinus lesions 2
• Eyelid malposition: Can lead to exposure and subsequent chemosis

Inflammatory Causes

• Allergic reactions: Common trigger for conjunctival edema
• Immune-mediated conditions:
  • Ocular mucous membrane pemphigoid (OMMP) 2
  • Graft-versus-host disease (GVHD) 2
  • Stevens-Johnson syndrome/toxic epidermal necrolysis 2
• Drug-induced reactions:
  • Dupilumab (used for atopic dermatitis) 2
  • Topical medications (e.g., pilocarpine, timolol) 2

Infectious Causes

• Bacterial conjunctivitis/infections
• Viral conjunctivitis (including adenoviral infections)

Systemic Causes

• Vascular disorders: Cavernous sinus thrombosis
• Neutropenia-associated infections: Can present with cutaneous manifestations including chemosis 2
• Thyroid ophthalmopathy: Associated with eyelid retraction and chemosis 2

Iatrogenic Causes

• Medication side effects: Loteprednol and other ophthalmic steroids can cause chemosis in 5-15% of patients 3
• Radiation therapy: Particularly to head and neck region
• Strabismus surgery: Listed as a common postoperative concern 2

Classification of Chemosis

Based on presentation pattern 1:

1. Type 1: Acute mild chemosis with complete lid closure
2. Type 2: Acute severe chemosis prohibiting complete lid closure (chemosis-induced lagophthalmos)
3. Type 3: Subchronic chemosis persisting longer than 3 weeks
4. Type 4: Chemosis associated with lower lid malposition

Management Approach

First-Line Treatments

• Lubricating eye drops/ointments: Preservative-free artificial tears to maintain ocular surface moisture
• Cold compresses: To reduce swelling and inflammation
• Elevation of the head: To reduce dependent edema

Second-Line Treatments

• Topical anti-inflammatory medications:
  • Ophthalmic steroids (e.g., loteprednol) for inflammatory causes 3
  • Caution: Monitor for increased intraocular pressure with steroid use
• Topical decongestants: To reduce vascular congestion
• Topical antihistamines: For allergic causes

Third-Line Treatments

• Compression bandaging/eye patching: For moderate to severe cases 1
• Topical adrenaline (1:1000): For severe refractory tarsal conjunctival chemosis 4
• Oral antihistamines: For allergic causes

Fourth-Line/Refractory Cases

• Drainage conjunctivotomy: Surgical drainage of subconjunctival fluid 1
• Temporary tarsorrhaphy: To protect the ocular surface and reduce exposure 1
• Treatment of underlying cause:
  • Correction of eyelid malposition
  • Management of thyroid eye disease
  • Treatment of infection or inflammatory condition

Prevention Strategies (Particularly for Surgical Cases)

• Intraoperative measures:
  • Minimize surgical exposure and manipulation of conjunctiva 5
  • Maintain moist ocular surface during procedures 5
• Postoperative care:
  • Early intervention with lubricants
  • Prompt management of eyelid malposition

Special Considerations

Chronic Localized Conjunctival Chemosis (CLCC)

• Defined as localized conjunctival edema persisting for ≥6 months 6
• May result from scarring and structural alteration of conjunctival lymphatics
• Often requires biopsy for diagnosis
• Management is challenging and may require surgical intervention

Chemosis in Neutropenic Patients

• May indicate serious infection requiring prompt antibiotic therapy 2
• Consider broad-spectrum antibiotics if associated with fever or other signs of infection

Chemosis After Strabismus Surgery

• Usually self-limiting and responds to conservative management 2
• Monitor for more serious complications like globe perforation or infection

Remember that while most cases of chemosis are benign and self-limiting, persistent cases warrant thorough investigation to rule out serious underlying pathology, particularly when associated with other ocular or systemic symptoms.