What is the treatment for an eye swollen shut?

Treatment for Eye Swollen Shut

Immediate ophthalmologic evaluation is essential to determine the underlying cause, as treatment varies dramatically depending on whether this represents preseptal cellulitis, orbital cellulitis, severe allergic reaction, Stevens-Johnson syndrome, acute angle-closure glaucoma, or infectious keratitis—each requiring distinct and urgent management strategies.

Initial Assessment Priorities

The swollen eye must be urgently evaluated to differentiate between vision-threatening and non-vision-threatening conditions:

• Check visual acuity immediately even if the eye is swollen shut—this is the single most important prognostic indicator 1, 2
• Assess for severe pain, photophobia, or decreased vision—these are warning signs demanding immediate ophthalmologic consultation 1
• Examine pupil reactivity and regularity—an irregular pupil after trauma suggests globe rupture requiring immediate referral 3
• Look for corneal involvement using fluorescein staining if the eye can be opened—epithelial defects require specific antibiotic prophylaxis 3

Differential Diagnosis-Driven Treatment

If Corneal Abrasion or Trauma is Present

Topical antibiotic eye drops are the preferred treatment due to their superior corneal penetration compared to ointments 3:

• Prescribe fluoroquinolone drops (moxifloxacin 0.5% or levofloxacin 1.5%) four times daily until complete epithelial healing 3
• Start treatment within 24 hours to prevent bacterial keratitis and ulceration 3
• Tetracycline ointment has limited utility as monotherapy because it lacks solubility and cannot penetrate the cornea significantly; it may be useful only at bedtime as adjunctive therapy in less severe cases 3
• For contact lens wearers, aggressive fluoroquinolone coverage is mandatory due to Pseudomonas risk—never patch these eyes 3

If Bacterial Keratitis is Suspected

Escalate immediately to loading doses if central infiltrate >2mm, deep stromal involvement, hypopyon, or corneal stromal loss is present 3:

• Initiate loading dose every 5-15 minutes, then hourly dosing with fourth-generation fluoroquinolones 3
• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases 3
• Do not use combination steroid-antibiotic drops initially—start antibiotic-only therapy, then add steroids only after 2-3 days once the organism is identified and epithelial defect is healing 4

If Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Daily ophthalmologic examination is mandatory during the acute illness 5:

• Apply nonpreserved lubricant drops (hyaluronate or carmellose) every 2 hours immediately 5
• Perform daily ocular hygiene using saline irrigation, squint hook, and forceps to remove inflammatory debris and break down conjunctival adhesions—blind sweeping with cotton buds is contraindicated 5
• In unconscious patients, establish a moisture chamber with polyethylene film to prevent corneal exposure and ulceration 5
• Use broad-spectrum topical antibiotics (moxifloxacin or levofloxacin four times daily) if corneal fluorescein staining or frank ulceration is present 5

If Acute Angle-Closure Glaucoma

This is an ophthalmologic emergency requiring immediate IOP reduction 5:

• Initiate medical therapy immediately: topical beta-blockers, alpha-2 agonists, topical/oral/IV carbonic anhydrase inhibitors, and oral/IV hyperosmotic agents 5
• Perform laser iridotomy as soon as feasible after corneal edema clears—this is the definitive treatment 5
• Miotics may be ineffective when IOP is markedly elevated due to pressure-induced ischemic paralysis of the pupillary sphincter 5

If Giant Papillary Conjunctivitis

Discontinue contact lens use immediately in conjunction with topical anti-inflammatory agents 5:

• Modify the causative entity: replace lenses more frequently, decrease wearing time, use preservative-free lens care systems, or switch to daily disposable lenses 5
• If corticosteroids are used, perform baseline and periodic IOP measurement and pupillary dilation to monitor for glaucoma and cataract 5

Critical Pitfalls to Avoid

• Never use eye patches in contact lens wearers with corneal abrasions—this increases the risk of secondary bacterial keratitis 3
• Never start with combination steroid-antibiotic drops for suspected bacterial keratitis—steroids must only be added after infection control is established 4
• Never delay ophthalmologic referral if there is high-velocity trauma, penetrating injury, irregular pupil, eye bleeding, or vision loss 3, 2
• Do not taper antibiotics below subtherapeutic dosing—this increases antibiotic resistance risk 4
• Rule out fungal keratitis before initiating corticosteroids—steroid use is a risk factor for requiring penetrating keratoplasty in fungal infections 4

Follow-Up Requirements

• Reassess within 24-48 hours to confirm healing and detect early signs of infection 3
• Modify therapy if no improvement occurs within 48 hours and consider reculture 4
• Educate patients about infection warning signs: increasing pain, purulent discharge, worsening vision—these require prompt return 3