What is the initial management for a patient presenting with chemosis?

Management of Chemosis

The initial management for a patient presenting with chemosis should include artificial tears for lubrication, cold compresses for comfort, and identification and treatment of the underlying cause. 1, 2

Assessment and Etiology

• Chemosis is characterized by swelling of the conjunctiva due to fluid accumulation in the subconjunctival space, which can be associated with various conditions including viral conjunctivitis, allergic reactions, or post-surgical complications 1, 3
• Clinical assessment should include checking for signs of viral conjunctivitis such as preauricular lymphadenopathy and follicular reaction 2
• Evaluate for potential causes including allergies, infection, inflammation, post-surgical complications, or rarely, systemic conditions 3, 4

Initial Management Approach

First-Line Interventions

• Apply artificial tears or lubricating eye drops to relieve irritation and maintain a moist ocular surface 1, 2
• Use cold compresses for 20-30 minutes per session with a barrier (such as a thin towel) between the cold container and skin to reduce swelling and provide comfort 2
• Patient education about the typically self-limiting nature of the condition is essential 2

Management Based on Underlying Cause

• For chemosis associated with viral conjunctivitis:

  • Focus treatment on the underlying viral infection 1
  • Use topical lubricants to improve comfort 1
  • Avoid antibiotics as they are ineffective for viral infections 1

• For severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis:

  • Topical corticosteroids may be considered under close supervision by an ophthalmologist 1
  • Daily ophthalmological review is necessary during the acute phase 1

Stepwise Management for Persistent Chemosis

1. Mild chemosis with complete lid closure:

   • Liberal lubrication with artificial tears 5
   • Cold compresses to reduce swelling 2

2. Severe chemosis prohibiting complete lid closure:

   • Ophthalmic steroid preparations and ocular decongestants 5
   • Eye patching may be beneficial 5

3. Subchronic chemosis persisting longer than 3 weeks:

   • Consider topical adrenaline (1:1000) for refractory cases that fail to respond to conservative measures 6
   • Referral to ophthalmology for specialized management 1

4. Chemosis associated with lid malposition:

   • Surgical consultation may be necessary 5
   • Procedures such as drainage conjunctivotomy or temporary tarsorrhaphy may be considered for persistent cases 5

Special Considerations

• For patients with Stevens-Johnson syndrome/toxic epidermal necrolysis with chemosis:

  • Urgent ophthalmology consultation is required 1
  • Two-hourly application of lubricant (e.g., nonpreserved hyaluronate or carmellose eye drops) 1
  • Daily ocular hygiene with saline irrigation to remove inflammatory debris 1

• For post-blepharoplasty chemosis:

  • Minimize surgical exposure and manipulation 7
  • Maintain a moist ocular surface 7
  • Follow a stepwise approach from lubricants to anti-inflammatories 7

Warning Signs Requiring Further Investigation

• Persistent pain with subconjunctival hemorrhage or chemosis 2
• Signs of infection accompanying the chemosis 2
• Chemosis that fails to improve with initial management within 1-2 weeks 2
• Visual changes or decreased visual acuity 1

Follow-up Recommendations

• Follow-up within 1-2 weeks is recommended if symptoms persist 2
• For patients treated with topical corticosteroids, monitoring for intraocular pressure elevation and cataract formation is necessary 1