What is the diagnosis for a left upper eyelid infection with redness and swelling?

Diagnosis of Left Upper Eyelid Infection with Redness and Swelling

The most likely diagnosis is preseptal cellulitis if there is diffuse eyelid swelling with erythema and warmth, or hordeolum (stye) if there is a localized, painful swelling at the eyelid margin. 1

Immediate Red Flag Assessment

Before determining the specific diagnosis, you must immediately rule out orbital cellulitis by checking for:

• Proptosis (bulging eye) 1
• Restricted or painful extraocular movements 1
• Vision changes 1
• Severe pain, especially with eye movement 1

If any of these are present, this is orbital cellulitis requiring immediate CT scan with contrast and IV antibiotics. 1

Primary Diagnostic Considerations

Preseptal Cellulitis

• Presents with eyelid swelling, erythema, and warmth without proptosis or impaired eye movements 1
• Patient appears systemically well without fever or chills in many cases 2
• Requires oral antibiotics covering Staphylococcus aureus and Streptococcus species 1
• Critical pitfall: Always obtain imaging if there is any suspicion of sinusitis (purulent nasal discharge, headache), as occult sinusitis can present as eyelid abscess 2

Hordeolum (Stye)

• Acute, painful, localized swelling at the eyelid margin with focal tenderness 1
• Managed with warm compresses and gentle lid massage 1
• Self-limited in most cases 1

Chalazion

• Firm, non-tender nodule within the tarsal plate 1
• Treated with warm compresses and observation for 4-6 weeks 1
• Refer to ophthalmology if persistent or recurrent, as this may indicate sebaceous carcinoma 3

Blepharitis as Contributing Factor

If the infection is associated with chronic eyelid margin inflammation, consider:

• Staphylococcal blepharitis: characterized by scaling, crusting, and erythema of the eyelid margin with collarette formation at the base of the eyelashes 4
• Anterior blepharitis: affects the eyelid skin, base of eyelashes, and eyelash follicles 4
• This is a chronic condition that cannot be permanently cured and requires long-term management 4

Essential Examination Steps

Evert the upper eyelid to examine the tarsal conjunctiva for:

• Papillary hypertrophy 1
• Follicles 1
• Perform fluorescein staining to rule out corneal involvement 1

Treatment Algorithm

For Preseptal Cellulitis:

• Start oral antibiotics immediately 1
• Apply warm compresses 1
• Follow up within 24-48 hours to ensure no progression 1
• Immediate referral if worsening or signs of orbital involvement develop 1

For Hordeolum or Chalazion:

• Warm compresses and gentle lid massage 1
• Observation for 4-6 weeks 1
• Refer to ophthalmology if persistent or recurrent 1

For Underlying Blepharitis:

• Lid hygiene measures provide symptomatic relief 5
• Topical antibiotics may provide symptomatic relief and eradicate bacteria from the eyelid margin 5
• Patient education that this is a chronic condition requiring long-term management 4

Critical Pitfalls to Avoid

• Do not miss occult sinusitis: Ask about purulent nasal discharge and headache, as extensive sinusitis can present as upper eyelid abscess 2
• Do not overlook malignancy: Chronic unilateral presentation unresponsive to standard therapy, or recurrent "chalazion" in the same location, requires biopsy to rule out sebaceous carcinoma 3, 6
• Do not delay imaging: If there is any concern for orbital involvement, obtain CT scan immediately 1