What is the differential diagnosis and treatment approach for eyelid swelling?

Eyelid Swelling: Differential Diagnosis and Treatment Approach

The differential diagnosis of eyelid swelling requires immediate distinction between preseptal and orbital cellulitis, as orbital cellulitis demands urgent hospitalization and IV antibiotics to prevent vision loss and life-threatening complications. 1, 2

Critical Red Flags Requiring Urgent Evaluation

Immediately assess for orbital cellulitis by examining for:

• Proptosis (eye bulging forward) 2, 3
• Impaired or painful extraocular movements/ophthalmoplegia 1, 2
• Decreased visual acuity 1, 2
• Severe headache or altered mental status (suggests intracranial extension) 1
• Fever and systemic toxicity 1

If any of these features are present, hospitalize immediately, obtain contrast-enhanced CT of orbits/sinuses, start IV antibiotics (vancomycin to cover methicillin-resistant organisms), and consult ophthalmology, otolaryngology, and infectious disease urgently. 1

Preseptal vs. Orbital Cellulitis Distinction

Preseptal cellulitis presents with:

• Eyelid erythema and edema confined to the eyelid 1, 2
• Normal extraocular movements 2, 3
• Normal visual acuity 2, 3
• No proptosis 2, 3

Management of preseptal cellulitis:

• Mild cases (eyelid <50% closed): Treat outpatient with high-dose amoxicillin-clavulanate and daily follow-up until definite improvement 1
• If no improvement in 24-48 hours or progressive infection: Hospitalize for IV antibiotics 1
• Important caveat: In children, preseptal cellulitis can progress to occlusion amblyopia if eyelid swelling persists, requiring close follow-up within 2 days 4

Common Non-Infectious Causes

Hordeolum (Stye)

Well-defined tender mass at the eyelid margin 2, 3

First-line treatment:

• Warm compresses for 5-10 minutes once or twice daily 5
• Gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01% after compresses 5
• Gentle massage to express gland contents 5

Second-line treatment:

• Topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins once daily or at bedtime 5
• Warning: If markedly asymmetric, resistant to therapy, or recurrent in same location, biopsy to exclude carcinoma 5

Chalazion

Non-tender mass within the mid-portion of the eyelid (chronic granulomatous inflammation of meibomian gland) 2, 6, 3

Treatment approach is similar to hordeolum with warm compresses and eyelid hygiene 5, 6

Contact Lens-Related Conditions

Giant papillary conjunctivitis (GPC):

• Lid swelling with ptosis in severe cases 1
• Papillary hypertrophy of superior tarsal conjunctiva 1
• Treatment: Discontinue contact lens wear, switch to daily disposables or increase replacement frequency, use preservative-free solutions, consider topical mast-cell stabilizers 1

Contact lens-related keratoconjunctivitis:

• Diffuse conjunctival injection with variable lid involvement 1
• Treatment: Contact lens abstinence for months until resolution, then modify lens type/care regimen 1

Floppy Eyelid Syndrome

Upper eyelid edema with easily everted upper lid (bilateral, often asymmetric) 1

• Associated with obesity, sleep apnea, and keratoconus 1
• Treatment: Temporary relief with nighttime eyelid taping or protective shield; definitive treatment requires surgical lid tightening 1
• Refer for sleep apnea evaluation 1

Dermatologic Causes

Contact dermatitis: Erythematous irritation with scaling 1, 2, 3

Atopic dermatitis: Raised, dry plaques 1, 2, 3

Herpes zoster ophthalmicus: Vesicles in dermatomal distribution 2, 3

Medication-induced: Conjunctival injection with punctal edema and eyelid contact dermatitis (common with glaucoma medications, NSAIDs, preservatives) 1

Less Common but Important Diagnoses

Blepharitis with preseptal cellulitis warning signs:

• Puffy eyelids with pain, erythema, proptosis, or vision changes require urgent ophthalmology referral 1
• Without warning signs, start warm compresses and lubrication with ophthalmology referral if no improvement 1

Malignancies (basal cell, squamous cell, sebaceous carcinoma):

• Consider in asymmetric, non-resolving lid lesions 2, 3
• Requires biopsy and excision by experienced surgeon 1

Autoimmune/systemic causes (less common initial presentations):

• Thyroid eye disease, Sjögren's syndrome, IgG4-related disease, orbital lymphoma 7
• Consider in persistent bilateral disease without clear infectious or allergic etiology 7

Key Clinical Pitfalls

• Never start steroids before ophthalmology exam in suspected uveitis or infectious keratitis, as this may worsen infection or mask accurate diagnosis 1
• Preseptal cellulitis in children requires follow-up within 2 days to prevent occlusion amblyopia from prolonged lid closure 4
• Long-term topical antibiotics may develop resistant organisms 5
• Patients with neurotrophic corneas or advanced glaucoma need special counseling about eyelid hygiene techniques to avoid corneal injury or pressure elevation 5