What is the treatment for a red and swollen upper eye?

Red and Swollen Upper Eye: Treatment Approach

The immediate priority is to distinguish between preseptal (periorbital) cellulitis and orbital cellulitis, as orbital involvement is a sight- and life-threatening emergency requiring urgent IV antibiotics and possible surgical intervention. 1, 2

Critical Initial Assessment

You must immediately evaluate for signs of orbital involvement versus simple preseptal infection:

Red flags indicating orbital cellulitis (requires emergency ophthalmology referral and IV antibiotics): 2

• Decreased vision or visual loss 3, 4
• Pain with eye movement 1
• Proptosis (eye bulging forward) 5
• Restricted or painful extraocular movements 2
• Relative afferent pupillary defect 2
• Severe or moderate pain (not just discomfort) 3

Features suggesting preseptal cellulitis (can be managed outpatient in healthy adults/older children): 6, 1

• Eyelid swelling and erythema without orbital signs 1
• Normal vision 2
• Full, painless eye movements 1
• No proptosis 5

Identify the Underlying Cause

Common predisposing factors to assess: 1

• Sinusitis (most common cause of orbital cellulitis - 79% of cases) 1
• Upper respiratory infection (68% of preseptal cases) 1
• Eyelid trauma (20% of preseptal cases) 1
• Dental infection (rare but can cause rapidly progressive orbital cellulitis with vision loss) 7
• Conjunctivitis (may present with eyelid swelling and chemosis) 3

Treatment Algorithm

If Orbital Cellulitis is Suspected:

Immediate actions required: 1, 2

• Emergency ophthalmology consultation 6, 2
• Orbital CT imaging to confirm diagnosis and assess for abscess 5, 7
• Admit for IV antibiotics immediately - do not delay for imaging 1, 2
• IV ceftriaxone + clindamycin is the most commonly used regimen (mean duration 8.6 days) 1
• Surgical drainage if abscess present or no improvement within 24-48 hours (required in 6% of cases) 1
• High-dose IV steroids if vision loss occurs (though vision may not recover) 7

The most common pathogens are Staphylococcus aureus, Streptococcus pneumoniae, and Staphylococcus epidermidis, though blood and skin cultures are usually negative. 1

If Preseptal Cellulitis (No Orbital Signs):

For healthy adults and older children: 6

• Oral broad-spectrum antibiotics (e.g., amoxicillin-clavulanate or cephalexin) 6
• Warm compresses for symptomatic relief 4
• Close follow-up within 24-48 hours to reassess for progression 2
• Immediate return if vision changes, increased pain, or worsening swelling 4, 2

For young children (<5 years), immunocompromised patients, or severe cases: 1

• Consider admission for IV antibiotics as they have higher risk of progression 1
• Children under 5 represent 85% of preseptal cellulitis cases but can progress to orbital involvement 1

If Conjunctivitis is the Cause:

Bacterial conjunctivitis with periocular swelling: 3

• 5-7 day course of broad-spectrum topical antibiotic (no specific agent is superior) 3
• Severe cases can mimic orbital cellulitis with marked chemosis and eyelid swelling 3
• Gonococcal conjunctivitis requires systemic antibiotics in addition to topical therapy due to risk of corneal perforation 3

Viral conjunctivitis with eyelid swelling: 3

• Supportive care only - artificial tears and cold compresses 3, 4
• Avoid antibiotics as they provide no benefit and may cause toxicity 3
• Severe adenoviral cases can cause marked chemosis and eyelid swelling resembling orbital cellulitis 3

Common Pitfalls to Avoid

• Failing to recognize orbital involvement early - delayed diagnosis can result in blindness, meningitis, or cerebral abscess 2
• Treating orbital cellulitis with oral antibiotics alone - this is inadequate and dangerous 1
• Assuming dental problems are benign - odontogenic orbital cellulitis can cause rapidly progressive tension orbit and irreversible blindness 7
• Using topical corticosteroids indiscriminately - they can worsen infections and increase intraocular pressure 3
• Delaying imaging or specialist referral when orbital signs are present - vision loss can occur within 24 hours 7, 2

Monitoring Requirements

For preseptal cellulitis on oral antibiotics: 2

• Reassess within 24-48 hours for improvement 2
• Instruct patient to return immediately if vision changes, pain worsens, or eye movement becomes restricted 4, 2

For orbital cellulitis on IV antibiotics: 1

• Daily ophthalmology examination to monitor vision and eye movements 2
• Repeat imaging if no improvement within 48 hours or clinical deterioration 1
• Mean IV antibiotic duration is 8.6 days, though some require longer courses 1