What is the treatment for a patient with a swollen eye?

Treatment of Swollen Eye

The treatment of a swollen eye depends critically on the underlying cause—begin with artificial tears for mild irritation, but immediately refer to ophthalmology within 1 week for any persistent swelling, within 2 days for symptomatic cases with visual changes, or urgently for severe symptoms, vision loss, or signs of infection. 1, 2

Initial Assessment Priorities

The swollen eye requires systematic evaluation to identify vision-threatening conditions versus benign causes:

• Check visual acuity immediately to assess for functional impairment 1
• Examine for warning signs requiring urgent ophthalmology referral: pain with eye movements, proptosis, movement restriction/diplopia, vision changes, or signs of infection 1
• Look for associated findings: redness, discharge, preauricular lymphadenopathy (suggests viral conjunctivitis), or corneal involvement 2, 1
• Assess eyelid involvement: puffy eyelids with pain and erythema suggest preseptal cellulitis requiring systemic antibiotics 1

Treatment Algorithm by Severity

Mild Swelling (Asymptomatic or Minimal Symptoms)

• Apply artificial tears for symptomatic relief of mild irritation 2
• Consider cold compresses for comfort (20-30 minutes per session with a barrier between ice and skin) 2
• Refer to ophthalmology within 1 week for evaluation 1
• Continue treatment while awaiting specialist assessment 1

Moderate Swelling (Symptomatic, Limiting Daily Activities)

• Hold any immune checkpoint inhibitors if applicable 1
• Refer to ophthalmology within 2 days before initiating treatment 1
• Coordinate treatment with ophthalmologist: may include topical steroids, cycloplegic agents, or systemic steroids depending on diagnosis 1
• Do NOT start steroids before ophthalmology exam—this can worsen infectious conditions like herpetic keratitis or mask accurate diagnosis 1

Severe Swelling (Marked Visual Impairment, Self-Care Limitations)

• URGENT ophthalmology referral (preferably same-day, before initiating treatment) 1
• Consider systemic steroids in addition to topical/periocular steroids only as recommended by ophthalmologist 1
• Permanently discontinue immune checkpoint inhibitors if applicable (though carefully selected cases may restart cautiously) 1

Specific Condition Management

If Viral Conjunctivitis Suspected (with subconjunctival hemorrhage or follicular reaction)

• Topical lubricants to improve comfort 2
• Avoid antibiotics—they are ineffective for viral infections 1, 2
• Consider topical corticosteroids only for severe cases with marked chemosis, lid swelling, or membranous conjunctivitis, under close ophthalmology supervision 1, 2
• Follow-up within 1-2 weeks if symptoms persist 2

If Corneal Edema Present

• Topical sodium chloride 5% drops or ointment for hyperosmotic effect 1
• Lower intraocular pressure if elevated (avoid prostaglandin analogues if inflammation suspected, avoid topical carbonic anhydrase inhibitors if endothelial dysfunction present) 1
• Add topical corticosteroid once infection ruled out, if inflammation present 1
• Bandage contact lens for painful bullous epithelial disease, with prophylactic broad-spectrum antibiotic 1

If Blepharitis (Eyelid Inflammation)

• Warm compresses and lubrication drops for initial management 1
• Refer to ophthalmology if symptoms do not improve 1
• Watch for preseptal cellulitis warning signs (eyelid swelling with pain and erythema) requiring systemic antibiotics 1

Critical Pitfalls to Avoid

• Never start topical steroids before ophthalmology examination—this can worsen herpetic keratitis, mask infection, or prevent accurate diagnosis 1
• Do not dismiss as benign without checking visual acuity—swelling can be the first sign of vision-threatening conditions 1, 3
• Do not delay referral for severe symptoms—conditions like acute angle-closure glaucoma, orbital cellulitis, or infectious keratitis require urgent specialist care 3, 4
• Avoid antibiotics for viral conjunctivitis—they provide no benefit and risk adverse effects 1, 2

When to Refer Urgently

Same-day ophthalmology consultation required for: 1, 3

• Visual acuity worse than 20/40
• Severe pain or pain with eye movements
• Proptosis or movement restriction
• Signs of infection with systemic symptoms
• Any concern for orbital cellulitis, acute glaucoma, or scleritis