Why are my eyelids puffy

Puffy Eyelids: Differential Diagnosis and Management

Puffy eyelids require immediate assessment to rule out orbital cellulitis—check for proptosis, painful or impaired eye movements, decreased vision, fever, or altered mental status, and if any are present, hospitalize immediately for IV antibiotics and urgent ophthalmology consultation. 1

Immediate Red Flag Assessment

Before considering benign causes, you must systematically exclude emergencies:

• Orbital cellulitis signs: Proptosis, impaired/painful extraocular movements, decreased visual acuity, severe headache, altered mental status, fever, or systemic toxicity require immediate hospitalization, contrast-enhanced CT of orbits/sinuses, IV antibiotics, and urgent multi-specialty consultation 1
• Preseptal cellulitis: If eyelid is <50% closed without orbital signs, treat with high-dose amoxicillin-clavulanate and daily follow-up; hospitalize if no improvement in 24-48 hours 1

Common Non-Infectious Causes

Hordeolum (Stye)

• First-line treatment: Warm compresses 5-10 minutes once or twice daily, gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01%, and gentle massage to express gland contents 1
• Second-line: Topical antibiotic ointment (bacitracin or erythromycin) to lid margins once daily or at bedtime 1

Floppy Eyelid Syndrome

This is an underrecognized cause of chronic eyelid swelling, particularly in specific populations:

• Clinical presentation: Upper eyelid edema, easily everted upper lids with simple elevation, horizontal lid laxity, diffuse papillary reaction of superior tarsal conjunctiva, often bilateral but asymmetric 2
• Key associations: Obesity, obstructive sleep apnea, upper-eyelid laxity, thyroid disease (especially Hashimoto's thyroiditis), and increased risk of keratoconus 2, 3
• Pathophysiology: Chronic nocturnal eyelid eversion causing upper-tarsal conjunctiva contact with bedding 2
• Treatment approach: Temporary relief with nighttime eyelid taping or protective shield; definitive treatment requires surgical lid tightening; refer for sleep apnea evaluation 1, 3

Contact Lens-Related Causes

• Giant papillary conjunctivitis: Discontinue contact lens wear, switch to daily disposables or increase replacement frequency, use preservative-free solutions, consider topical mast-cell stabilizers 1
• Contact lens keratoconjunctivitis: Requires contact lens abstinence for months until resolution, then modify lens type/care regimen 1

Medication-Induced Eyelid Swelling

• Common culprits: Topical glaucoma medications, NSAIDs, antibiotics, antivirals—often related to preservatives 2
• Distinctive features: Conjunctival injection, punctal edema, inferior fornix and bulbar conjunctival follicles, contact dermatitis of eyelids with erythema and scaling 2
• Management: Discontinue the offending medication 1

Dupilumab-Associated Ocular Surface Disease

• Presentation: Bilateral conjunctival and limbal injection, watery or mucous discharge, eyelid thickening, typically within weeks to months of initiation 2
• Risk factors: Severe atopic dermatitis, history of atopic conjunctivitis, low serum dupilumab levels 2
• Natural history: Often manageable with treatment; most cases resolve while continuing therapy 2

Blepharitis-Related Eyelid Swelling

Chronic inflammation of the eyelid margins can present with eyelid edema:

• Key examination findings: Abnormal eyelid position, loss/breakage of eyelashes, vascularization or hyperemia of eyelid margins, abnormal deposits at lash bases, chalazion/hordeolum, scarring 2
• Associated systemic conditions: Rosacea (look for rhinophyma, erythema, telangiectasia, papules, pustules), atopic dermatitis, psoriasis, graft-versus-host disease 2
• Slit-lamp findings: Abnormalities of meibomian orifices (capping, pouting, metaplasia), character of meibomian secretions (expressibility, thickness, turbidity), tarsal conjunctival inflammation 2

Systemic Disease Considerations

Nephrotic Syndrome

Critical pitfall: In children with puffy eyelids and facial swelling initially attributed to allergy, nephrotic syndrome must be excluded with urinalysis and serum albumin 4

• Presentation: Bilateral periorbital edema, often with facial swelling 4
• Diagnostic approach: Urinalysis showing proteinuria and low serum albumin confirm diagnosis 4
• Importance: Early recognition allows initiation of specific therapy that induces rapid remission 4

Dry Eye Syndrome

Paradoxically, dry eye can present with eyelid swelling due to chronic inflammation:

• External examination findings: Incomplete eyelid closure, incomplete/infrequent blink, eyelid lag or retraction, erythema of eyelid margins 2
• Associated conditions: Scleroderma, rosacea, seborrhea, rheumatoid arthritis, Sjögren's syndrome 2
• Tear film assessment: Reduced tear meniscus height, decreased tear break-up time, foamy discharge on lid margin 2

Immune-Mediated Causes

Ocular Mucous Membrane Pemphigoid

• Presentation: Eyelid thickening, bilateral (often asymmetric) bulbar conjunctival injection, papillary conjunctivitis, progressive conjunctival scarring beginning in fornices 2
• Demographics: More common in women, onset generally over age 60 2
• Sequelae: Progressive conjunctival shrinkage, symblepharon, entropion, trichiasis, corneal ulcers/perforation 2

Critical Clinical Pitfalls

• Never start steroids before ophthalmology examination in suspected uveitis or infectious keratitis, as this may worsen infection or mask accurate diagnosis 1
• Do not attribute pediatric periorbital edema to allergy without first obtaining urinalysis to exclude nephrotic syndrome 4
• Recognize floppy eyelid syndrome in obese patients with sleep apnea presenting with chronic eyelid irritation—simple eyelid eversion during examination reveals the diagnosis 2, 3
• Biopsy suspected malignancies (basal cell, squamous cell, sebaceous carcinoma) with excision by an experienced surgeon 1