What causes a swollen eyelid and how is it treated?

Swollen Eyelid: Causes and Treatment

Direct Answer

A swollen eyelid most commonly results from infectious causes (bacterial or viral conjunctivitis, hordeolum, preseptal cellulitis), allergic reactions, or inflammatory conditions, and treatment depends entirely on identifying the specific etiology through key clinical features—particularly the presence or absence of pain, discharge character, and associated systemic symptoms. 1, 2

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Algorithmic Approach to Diagnosis

Step 1: Assess for Red Flags Requiring Immediate Ophthalmology Referral

• Visual loss or decreased vision 2
• Moderate to severe pain (suggests corneal involvement, orbital cellulitis, or severe infection) 2
• Severe purulent discharge (particularly with marked lid edema—consider gonococcal conjunctivitis) 2
• Corneal involvement (opacity, infiltrate, or ulceration) 2
• Lack of response to initial therapy 2
• History of immunocompromise 2

Step 2: Determine Primary Etiology Based on Clinical Features

Infectious Causes

Viral Conjunctivitis:

• Abrupt onset, initially unilateral but often becomes sequentially bilateral within days 1, 2
• Watery discharge with follicular reaction on inferior tarsal conjunctiva 2
• Preauricular lymphadenopathy is characteristic 2
• Chemosis and eyelid swelling can be severe enough to resemble orbital cellulitis 1, 2
• Often accompanied by concurrent upper respiratory infection 1, 2
• Self-limited, resolving within 5-14 days 1, 2

Bacterial Conjunctivitis:

• Mucopurulent discharge with matted eyelids upon awakening 2
• Papillary rather than follicular reaction on tarsal conjunctiva 2
• May be associated with bacterial otitis media, sinusitis, or pharyngitis in children 2
• Preauricular lymphadenopathy less common unless hypervirulent organism 2

Gonococcal Conjunctivitis (Medical Emergency):

• Marked eyelid edema, intense bulbar conjunctival injection, copious purulent discharge 2
• Can progress to corneal perforation within 24-48 hours 2
• Requires immediate systemic plus topical antibiotic therapy 2

Herpes Simplex Virus:

• Usually unilateral (bilateral in atopic, pediatric, or immunocompromised patients) 2
• Vesicular rash or ulceration of eyelids is pathognomonic 2
• May have dendritic epithelial keratitis on cornea 2

Molluscum Contagiosum:

• Shiny, dome-shaped umbilicated lesions on eyelid skin or margin 3
• Causes unilateral follicular conjunctivitis from viral shedding 3
• Multiple/large lesions with minimal inflammation suggest HIV infection 3

Preseptal Cellulitis:

• Eyelid erythema, warmth, and tender swelling without orbital signs 4
• Normal extraocular motility, no proptosis, no vision changes 4
• Often follows upper respiratory infection or local trauma 4

Hordeolum (Stye):

• Acute, localized, painful swelling at eyelid margin (external) or tarsal plate (internal) 4
• Tender, erythematous nodule with possible pointing 4

Chalazion:

• Painless, firm nodule within tarsal plate 4
• Gradual onset over weeks 4
• Chronic/recurrent chalazions warrant biopsy to rule out sebaceous carcinoma 1

Allergic Causes

Allergic Conjunctivitis:

• Bilateral presentation with seasonal or perennial pattern 2
• Itching is the most consistent and distinguishing feature 2
• Watery discharge, no preauricular lymphadenopathy, no matted eyelids 2
• Often concurrent allergic rhinitis or asthma 2

Giant Papillary Conjunctivitis:

• Papillary hypertrophy of superior tarsal conjunctiva with mucoid discharge 1
• Associated with contact lens wear, exposed sutures, or ocular prosthesis 1
• In severe cases: lid swelling and ptosis 1

Contact Dermatitis:

• Eyelid erythema, scaling, and edema 1
• History of new cosmetics, medications, or topical agents 1

Inflammatory/Mechanical Causes

Floppy Eyelid Syndrome:

• Upper eyelid easily everted with simple elevation 1
• Upper eyelid edema, horizontal lid laxity 1
• Associated with obesity, sleep apnea, and upper-eyelid laxity 1
• Chronic ocular irritation from nocturnal eyelid ectropion 1

Blepharitis:

• Chronic eyelid margin inflammation with crusting and debris 4
• May have associated meibomian gland dysfunction 4

Neoplastic Causes (Chronic/Recurrent Cases)

Sebaceous Carcinoma:

• Unilateral, chronic/recurrent presentation mimicking chalazion 1
• History of multiple chalazion excisions is suspicious 1
• Hard, nonmobile mass with yellowish discoloration 1
• Can metastasize—requires urgent biopsy 1

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Treatment by Etiology

Viral Conjunctivitis

Primary Management:

• No antibiotics—they provide no benefit and may cause toxicity 2
• Supportive care only: artificial tears for symptomatic relief 2
• Topical antihistamines for symptomatic relief 2
• Cold compresses 2

Patient Education:

• Highly contagious—minimize contact with others for 10-14 days from symptom onset 2
• Proper hand hygiene with soap and water 2
• Avoid sharing towels, pillows, or personal items 2
• Disinfect surfaces with EPA-registered hospital disinfectant 2

Severe Cases:

• Topical corticosteroids may be considered for pseudomembranes or severe inflammation, but require close ophthalmology follow-up for IOP monitoring 2
• Caution: Corticosteroids prolong viral shedding and worsen HSV infections 2

Follow-up:

• Re-evaluate within 1 week if severe 2
• Return if symptoms persist beyond 2-3 weeks 2

Bacterial Conjunctivitis

Mild Cases:

• Usually self-limited and may resolve without treatment 1, 2
• 5-7 day course of broad-spectrum topical antibiotic (e.g., erythromycin, polymyxin B-trimethoprim, fluoroquinolones) 1, 2
• No specific agent is superior—choose most convenient or least expensive option 2

Moderate to Severe Cases:

• 5-7 day course of broad-spectrum topical antibiotic is usually effective 2
• Consider fluoroquinolones for MRSA coverage 2

Gonococcal Conjunctivitis:

• Requires systemic treatment plus topical therapy 2
• Immediate ophthalmology consultation 2

Chlamydial Conjunctivitis:

• Requires systemic treatment (azithromycin or doxycycline) 2
• Evaluate and treat sexual partners 2

Allergic Conjunctivitis

First-Line:

• Environmental modifications: wear sunglasses as barrier to airborne allergens, cold compresses, refrigerated artificial tears 2
• Avoid eye rubbing 2
• Topical antihistamines with mast cell-stabilizing activity (e.g., olopatadine, ketotifen) 2

Refractory Cases:

• Short-term topical corticosteroids (1-2 week course) with low side-effect profile 2
• Topical cyclosporine 0.05% for chronic cases 1
• Allergen-specific immunotherapy for severe cases (more effective in children) 2

Giant Papillary Conjunctivitis

• Discontinue contact lens wear until cornea returns to normal 1
• Brief (1-2 weeks) course of topical corticosteroids 1
• Longer-term topical cyclosporine 0.05% 1
• Review contact lens fit, type, and care regimen upon resolution 1
• Consider alternatives to contact lenses (eyeglasses or refractive surgery) 1

Molluscum Contagiosum

Definitive Treatment:

• Physical removal of eyelid lesion: incision and curettage (aggressive enough to cause bleeding), simple excision, excision with cautery, or cryotherapy 1, 3
• Examine carefully for nascent lesions and treat simultaneously to reduce recurrence 3
• Conjunctivitis may require weeks to resolve after lesion elimination 3

Special Consideration:

• Multiple/large lesions with minimal inflammation warrant HIV testing 3

Preseptal Cellulitis

• Oral antibiotics covering Staphylococcus and Streptococcus species 4
• Warm compresses 4
• Close follow-up to ensure no progression to orbital cellulitis 4

Hordeolum

• Warm compresses 4 times daily 4
• Eyelid hygiene 4
• Topical antibiotic ointment (e.g., erythromycin) if pointing 4
• Incision and drainage if not resolving 4

Chalazion

• Warm compresses and eyelid massage 4
• Intralesional corticosteroid injection if persistent 4
• Surgical excision if refractory 4
• Biopsy if chronic/recurrent to rule out sebaceous carcinoma 1

Floppy Eyelid Syndrome

• Eyelid taping at night to prevent eversion 1
• Lubricating ointment at bedtime 1
• Surgical eyelid tightening for severe cases 1
• Evaluate and treat sleep apnea 1

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Common Pitfalls to Avoid

• Do not use topical antibiotics for viral conjunctivitis—they provide no benefit and may delay diagnosis of other conditions 2
• Do not use topical corticosteroids indiscriminately—they prolong adenoviral infections, worsen HSV infections, and cause increased IOP and cataracts 2
• Do not ignore chronic/recurrent chalazions—they may represent sebaceous carcinoma requiring biopsy 1
• Do not miss gonococcal conjunctivitis—it can cause corneal perforation within 24-48 hours 2
• Avoid contact lens wear during any infectious conjunctivitis 2
• Do not use topical vasoconstrictors chronically—rebound hyperemia occurs 2