Treatment of Eye Swollen Shut
The immediate priority is to determine whether this represents orbital cellulitis versus preseptal cellulitis, as orbital cellulitis is a vision-threatening and potentially life-threatening emergency requiring immediate IV antibiotics and hospitalization, while preseptal cellulitis can often be managed with oral antibiotics. 1
Critical Initial Assessment
The following features distinguish these conditions and guide urgency:
- Vision changes or ophthalmoplegia (impaired eye movements) indicate orbital cellulitis and require immediate emergency department referral 1, 2
- Proptosis (forward displacement of the globe) suggests orbital involvement requiring urgent ophthalmology consultation 1
- Pain with eye movements is characteristic of orbital cellulitis 1
- Normal vision and extraocular movements with lid swelling alone suggest preseptal cellulitis 1
Essential Examination Elements
Every patient requires:
- Visual acuity testing in both eyes 2
- Pupillary examination to assess for afferent pupillary defect 2
- Extraocular movement testing to identify ophthalmoplegia 1, 2
- Assessment for proptosis by viewing from above the patient's head 1
Management Based on Diagnosis
Orbital Cellulitis (Vision-Threatening Emergency)
Immediate emergency department referral or direct ophthalmology consultation is mandatory 1, 2
Treatment requires:
- Intravenous broad-spectrum antibiotics covering Staphylococcus aureus, Streptococcus species, and anaerobes 1
- Hospital admission for monitoring and IV therapy 1
- CT imaging of orbits to assess for abscess formation 1
- Daily ophthalmologic review during acute illness 3
Preseptal Cellulitis (Non-Vision-Threatening)
For adults without systemic signs:
- Oral antibiotics covering skin flora (cephalexin, amoxicillin-clavulanate, or clindamycin) 1
- Warm compresses applied to affected area 1
- Close follow-up within 24-48 hours to ensure improvement 1
- Immediate referral if worsening or development of orbital signs 1
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
If eyelid swelling occurs with mucocutaneous sloughing or systemic illness:
- Immediate ophthalmology consultation as early intervention prevents late complications 3
- Apply ocular lubricant (nonpreserved hyaluronate or carmellose) every 2 hours 3
- Daily ophthalmological review is necessary during acute illness 3
- Topical corticosteroid drops (nonpreserved dexamethasone 0.1% twice daily) may reduce ocular surface damage 3
- Broad-spectrum topical antibiotic prophylaxis (moxifloxacin four times daily) in presence of corneal staining 3
- Ocular hygiene daily by ophthalmologist or trained nurse to remove debris and break adhesions 3
Floppy Eyelid Syndrome
For chronic lid swelling with laxity:
- Temporary relief with taping eyelids shut or protective shield while sleeping 3
- Lubricants for mild cases 3
- Surgical procedures (lateral canthus repair, horizontal lid shortening) for definitive therapy 3
Common Pitfalls to Avoid
- Never assume benign etiology without checking vision and eye movements - missing orbital cellulitis can result in blindness or death 1, 2
- Do not delay referral for suspected orbital cellulitis to obtain imaging first - refer immediately 2
- Avoid pressure patching in contact lens wearers with trauma due to infection risk 3
- Consider chemical injury - if suspected, irrigate immediately for at least 30 minutes before any other intervention 2
- In unconscious patients with lid swelling, prevention of corneal exposure is essential using moisture chamber with polyethylene film 3
Special Considerations
Pediatric Patients
- Dacryocystitis (infected nasolacrimal sac) presents with erythema, swelling, warmth over lacrimal sac and requires urgent ophthalmology referral due to risk of meningitis and sepsis 4
- Consider child abuse if unusual presentation or inconsistent history 4