What is the diagnosis and treatment for a 55-year-old female with watery swelling of the right eye and periorbital swelling?

Diagnosis and Management of Unilateral Periorbital Swelling with Watery Discharge

The most likely diagnosis is viral conjunctivitis, which should be managed with supportive care and close monitoring for complications, while ruling out more serious conditions like preseptal cellulitis or allergic reactions. 1

Differential Diagnosis

The presentation of watery swelling and periorbital edema in a 55-year-old female requires systematic evaluation of several key possibilities:

Most Likely: Viral Conjunctivitis

• Unilateral presentation with watery discharge, periorbital swelling, and conjunctival injection strongly suggests viral conjunctivitis 1
• Adenoviral conjunctivitis characteristically presents with abrupt onset, bulbar conjunctival injection, watery discharge, chemosis, and eyelid swelling 1
• Look specifically for: preauricular lymphadenopathy, follicular reaction on inferior tarsal conjunctiva, and petechial hemorrhages 1
• The condition is self-limited, typically improving within 5-14 days 1

Critical to Rule Out: Preseptal vs. Orbital Cellulitis

• Check for pain, fever, restricted extraocular movements, and vision changes 2
• Preseptal cellulitis causes diffuse lid swelling with normal vision and eye movements, while orbital cellulitis impairs extraocular movements and vision 2
• Orbital cellulitis requires urgent referral and IV antibiotics 2

Other Considerations

• Herpes simplex virus (HSV): Look for vesicular rash or ulceration of eyelids, dendritic keratitis on corneal examination 1
• Allergic reaction/angioedema: Typically more rapid onset (1-2 hours), may have medication exposure history 3
• Clogged tear duct with dacryocystitis: Presents with excessive tearing, swelling near inner canthus, and mucoid discharge rather than watery discharge 4

Essential Examination Elements

Perform these specific assessments immediately:

• Visual acuity testing: Any decrease requires urgent evaluation 4
• Pupillary examination: Check for afferent pupillary defect or anisocoria 5
• Extraocular movements: Restriction suggests orbital involvement 2
• Evert the eyelid: Look for follicular reaction (viral) vs. papillary reaction (allergic) 1
• Palpate preauricular lymph nodes: Enlargement supports viral etiology 1
• Slit-lamp examination if available: Assess for corneal involvement, anterior chamber reaction 1
• Check for vesicular lesions: HSV or varicella-zoster virus (VZV) present with characteristic vesicles 1

Treatment Algorithm

For Viral Conjunctivitis (Most Likely)

Supportive care is the mainstay, as the condition is self-limited 1

• Cool compresses and artificial tears for symptom relief 1
• Strict hand hygiene and avoidance of eye touching to prevent spread 1
• No contact lens wear until resolution 6
• Patient should avoid work/school for 5-7 days to prevent transmission 1
• Follow-up in 5-7 days if not improving or if symptoms worsen 1

Red Flags Requiring Urgent Referral

Immediately refer if any of the following are present: 4

• Decreased vision or photophobia
• Corneal involvement (opacity, infiltrate)
• Severe pain disproportionate to findings
• Restricted extraocular movements
• Fever or systemic symptoms
• Membrane or pseudomembrane formation (higher risk of severe sequelae) 1

If Bacterial Conjunctivitis Suspected

• Consider topical antibiotics only if mucopurulent discharge, severe symptoms, or need for earlier return to work 4
• Moxifloxacin 0.5% one drop three times daily for 7 days is an appropriate fluoroquinolone option 6
• However, most cases of conjunctivitis are viral and do not benefit from antibiotics 1, 4

If HSV Suspected

• Topical antiviral therapy (e.g., ganciclovir gel or trifluridine drops) if dendritic keratitis present 1
• Oral antivirals may be considered for severe cases 1
• Usually subsides within 4-7 days but requires monitoring for complications 1

Common Pitfalls to Avoid

• Do not prescribe topical antibiotics reflexively: Most cases are viral and antibiotics provide no benefit while increasing resistance and cost 1, 4
• Do not miss orbital cellulitis: Always check extraocular movements and vision; orbital involvement requires immediate hospitalization 2
• Do not overlook HSV: Missing dendritic keratitis can lead to stromal keratitis, scarring, and permanent vision loss 1
• Do not allow contact lens wear: Patients with any signs of conjunctivitis should discontinue lens wear to prevent complications 6
• Do not ignore severe cases: Pseudomembrane formation in viral conjunctivitis is associated with higher rates of severe sequelae including corneal scarring and requires closer monitoring 1

Expected Course and Follow-up

• Viral conjunctivitis typically improves within 5-14 days 1
• Severe cases may develop subepithelial infiltrates that can persist for weeks to months 1
• Schedule follow-up if symptoms persist beyond 2 weeks or worsen at any time 1
• The fellow eye may become involved sequentially in 50% of cases 1