What is the treatment for a 9-year-old with a swollen upper eyelid, without conjunctivitis, discharge, or fever?

Swollen Upper Eyelid in a 9-Year-Old Without Conjunctivitis

The most likely diagnosis is preseptal cellulitis or hordeolum/chalazion, and you should immediately assess for orbital involvement by checking for proptosis, restricted eye movements, and pain with eye movement—if any are present, obtain urgent CT imaging and start IV antibiotics; if absent, treat with warm compresses and consider oral antibiotics if significant eyelid erythema and tenderness are present. 1

Immediate Assessment Priorities

Check for orbital involvement immediately by examining for:

• Proptosis (forward displacement of the eye)
• Restricted or painful extraocular movements
• Vision changes or decreased visual acuity
• Severe pain, especially with eye movement 1

If any of these red flags are present, this represents orbital cellulitis requiring immediate CT scan with contrast and IV antibiotics—this is a medical emergency that can progress to vision loss, meningitis, or brain abscess. 1

Most Likely Diagnoses Without Conjunctivitis

Preseptal Cellulitis

• Presents with eyelid swelling, erythema, and warmth but WITHOUT proptosis or impaired eye movements 1
• The absence of conjunctival injection or discharge helps distinguish this from infectious conjunctivitis 2, 3
• Treatment: Oral antibiotics covering Staphylococcus aureus and Streptococcus species (amoxicillin-clavulanate is first-line) 1
• Close follow-up within 24-48 hours is mandatory to ensure no progression to orbital involvement 1

Hordeolum or Chalazion

• Hordeolum (stye): Acute, painful, localized swelling at the eyelid margin with focal tenderness 2
• Chalazion: Firm, non-tender nodule within the tarsal plate, may cause diffuse lid swelling if inflamed 4
• Initial management: Warm compresses for 5-10 minutes, 3-4 times daily, with gentle lid massage 2
• Most resolve spontaneously within 4-6 weeks with conservative therapy 4
• Red flag: If a "chalazion" recurs in the same location or persists beyond 6 weeks despite treatment, biopsy is mandatory to rule out sebaceous carcinoma 4

Giant Papillary Conjunctivitis (GPC)

• Can present with lid swelling and ptosis in severe cases, but typically has mucoid discharge and papillary hypertrophy of the upper tarsal conjunctiva 2
• Usually associated with contact lens wear (not typical in a 9-year-old unless they wear contacts) 2
• The absence of discharge makes this less likely 2

Floppy Eyelid Syndrome

• Presents with upper eyelid edema and easily everted upper lid 2
• Associated with obesity and sleep apnea 2
• Less common in children but should be considered if the child is obese 2

Examination Technique

Evert the upper eyelid to examine the tarsal conjunctiva:

• Look for papillary hypertrophy (suggests allergic or contact lens-related disease) 2
• Check for follicles (suggests viral or chlamydial infection, though you note no conjunctivitis) 2
• Assess for foreign body or embedded material 3

Perform fluorescein staining to rule out corneal involvement, which would require immediate ophthalmology referral 1, 5

Treatment Algorithm

If Preseptal Cellulitis is Suspected:

1. Start oral antibiotics (amoxicillin-clavulanate 45 mg/kg/day divided twice daily) 1
2. Warm compresses to reduce swelling 2
3. Follow-up within 24-48 hours to ensure no progression 1
4. Immediate referral if worsening or any signs of orbital involvement develop 1

If Hordeolum/Chalazion is Suspected:

1. Warm compresses for 5-10 minutes, 3-4 times daily 2
2. Gentle lid massage after warming to express meibomian secretions 2
3. Lid hygiene with diluted baby shampoo or commercial lid cleanser 2
4. Observation for 4-6 weeks—most resolve spontaneously 4
5. Ophthalmology referral if persistent beyond 6 weeks or recurrent in same location (to rule out malignancy) 4

If No Clear Diagnosis:

• Consider allergic causes (vernal or atopic keratoconjunctivitis can present with lid swelling even without obvious conjunctival injection) 2
• Trial of oral antihistamine and cool compresses 2
• Ophthalmology referral if no improvement within 1 week or if vision is affected 1

Critical Pitfalls to Avoid

• Never assume isolated lid swelling is benign—always rule out orbital involvement first 1
• Do not prescribe topical antibiotics alone for preseptal cellulitis—systemic antibiotics are required 1
• Do not ignore a recurrent "chalazion"—this can be sebaceous carcinoma masquerading as benign disease and requires biopsy 4
• Always check visual acuity and perform fluorescein staining—corneal involvement changes management entirely 1, 5