What is the treatment for chemosis?

Treatment of Chemosis

Initiate topical corticosteroids immediately for marked chemosis with lid swelling or epithelial sloughing, using preservative-free dexamethasone 0.1% when corneal defects are present. 1

Immediate Assessment

Before initiating treatment, determine the underlying cause and severity:

• Examine for corneal epithelial defects using fluorescein staining with cobalt blue light to guide formulation selection 1
• Grade severity by assessing conjunctival hyperemia, pseudomembrane formation, lagophthalmos, corneal exposure, or symblepharon formation 1
• Distinguish infectious from inflammatory etiologies, as this fundamentally changes management approach 1

First-Line Pharmacologic Management

Topical Corticosteroids (Primary Treatment)

• Start dexamethasone 0.1% immediately for marked chemosis, lid swelling, or epithelial sloughing 1
• Use preservative-free formulations when any corneal epithelial defect is present to avoid additional surface damage 1
• Monitor closely for complications: Check intraocular pressure and perform pupillary dilation periodically to evaluate for glaucoma and cataract with prolonged use 2, 1
• Taper once inflammation is controlled rather than abrupt discontinuation 2

Critical caveat: In adenoviral conjunctivitis with severe chemosis, topical corticosteroids reduce symptoms and may prevent scarring, but animal studies suggest they may prolong viral shedding—though human data are lacking 2

Adjunctive Topical Therapy

Artificial Tears

• Apply preservative-free artificial tears (hyaluronate or carmellose) every 2 hours throughout the acute phase 1
• Avoid preserved formulations when severe epithelial defects exist, as these worsen surface damage 1

Prophylactic Antibiotics

• Add broad-spectrum topical antibiotics (moxifloxacin or levofloxacin) four times daily when corneal epithelial defects are present to prevent secondary infection 1

Alternative Agents for Specific Etiologies

• Topical antihistamines may be added for allergic chemosis 2
• Povidone-iodine 0.4-0.6% alone or combined with dexamethasone 0.1% shows promise in adenoviral cases for reducing viral titers and shortening clinical course 2
• Topical adrenaline (1:1000) can be effective for severe, refractory tarsal conjunctival chemosis when conservative therapies fail 3

Daily Ophthalmologic Care

• Mandatory daily ophthalmologic review during the acute phase to monitor progression and complications 1
• Daily removal of inflammatory debris and lysis of conjunctival adhesions by an ophthalmologist or trained nurse using saline irrigation, squint hook, and forceps 1
• Debride membranes if membranous conjunctivitis is present to prevent corneal epithelial abrasions or permanent cicatricial changes (e.g., foreshortening of conjunctival fornix) 2

Mechanical and Supportive Measures

• Apply cold compresses to reduce edema and inflammation for symptomatic relief 1
• Establish a moisture chamber with polyethylene film if significant chemosis or lid involvement prevents complete closure, preventing corneal exposure and ulceration 1
• Consider eye-patching for moderate to severe cases as part of the treatment continuum 4

Surgical Intervention (Refractory Cases)

For chemosis persisting beyond 3 weeks (subchronic) or causing lagophthalmos:

• Drainage conjunctivotomy can be performed for persistent cases 4
• Temporary tarsorrhaphy may be necessary when chemosis prohibits complete lid closure 4

Critical Pitfalls to Avoid

• Never delay ophthalmologic consultation—daily review is mandatory during the acute phase 1
• Never use preserved artificial tears with severe epithelial defects 1
• Never use topical steroids without close monitoring for infection, especially when corneal epithelial defects exist 1
• Never use antibiotics routinely in viral conjunctivitis without specific indication, as this risks adverse effects without benefit 2

Follow-Up Strategy

• Re-evaluate within 1 week for patients with severe disease, corneal epithelial ulceration, or membranous conjunctivitis 2
• Instruct patients to return if symptoms of red eye, pain, or decreased vision persist after 2-3 weeks in non-steroid-treated cases 2
• Monitor for subepithelial infiltrates in adenoviral cases, which typically occur 1+ weeks after onset and may require topical corticosteroids if causing blurring, photophobia, or decreased vision 2