What are the causes and treatments of eye swelling?

Eye Swelling: Causes and Treatment

Primary Causes by Category

Infectious Etiologies

Bacterial conjunctivitis and orbital cellulitis are the most critical infectious causes requiring immediate differentiation. 1

• Chlamydial conjunctivitis presents with bulbar conjunctival injection, follicular reaction, mucoid discharge, and preauricular lymphadenopathy, with potential for corneal scarring if untreated 1
• Parinaud oculoglandular syndrome (most commonly from Bartonella henselae in cat scratch disease) causes unilateral granulomatous follicular conjunctivitis with ipsilateral regional lymphadenopathy, fever, and eyelid swelling 1
• Orbital cellulitis presents with proptosis, restricted ocular movements, relative afferent pupillary defect, and fever—this is an emergency requiring immediate CT imaging and parenteral antibiotics to prevent vision loss and intracranial complications 2
• Preseptal cellulitis causes periorbital swelling without proptosis or restricted eye movements, but can progress to orbital involvement if inadequately treated 2
• Acute dacryocystitis presents with erythema, swelling, warmth, and tenderness over the lacrimal sac, requiring early treatment to prevent periorbital cellulitis, meningitis, and sepsis 3
• Viral causes include herpes simplex and varicella zoster producing vesicular eyelid lesions, and molluscum contagiosum causing shiny, dome-shaped umbilicated lesions with follicular conjunctivitis 4

Allergic and Immunologic Causes

• Allergic contact dermatitis from cosmetics or ophthalmic preparations causes conjunctival injection, blepharitis, periorbital dermatitis, and lid edema with itching 5
• Giant papillary conjunctivitis occurs with contact lens wear, presenting with papillary hypertrophy of superior tarsal conjunctiva and mucoid discharge 1
• Hereditary angioedema requires recurrent angioedema without hives, strong family history, and at least 95% of patients with C1 inhibitor deficiency have reduced C4 levels even between attacks 6

Medication-Induced Causes

Imatinib causes periorbital edema in up to 70% of treated patients, making it the most common ocular side effect through platelet-derived growth factor receptor inhibition. 6

• ACE inhibitors combined with neprilysin inhibitors are contraindicated due to unacceptable angioedema risk through impaired bradykinin degradation, and ACE inhibitor-induced angioedema can persist for at least 6 weeks after discontinuation 6
• Amantadine produces reversible or permanent endothelial dysfunction depending on duration of use 6
• Topical medications including glaucoma medications, NSAIDs, antibiotics, and antivirals cause conjunctival injection, punctal edema, inferior fornix follicles, and keratitis, especially with preservatives 1

Corneal Causes of Swelling

• Fuchs dystrophy causes diurnal variation with worse vision upon waking that improves later in the day due to evaporation 6
• Elevated intraocular pressure from topical corticosteroids or chronic glaucoma causes acute corneal edema 6
• Moderate to severe corneal or intraocular inflammation produces edema 6

Eyelid and Adnexal Causes

• Floppy eyelid syndrome presents with upper eyelid edema, easily everted upper lid, horizontal lid laxity, diffuse papillary reaction, and is associated with obesity and sleep apnea 1
• Contact lens-related keratoconjunctivitis ranges from mild to diffuse conjunctival injection with focal or diffuse corneal neovascularization and limbal edema 1
• Nasolacrimal duct obstruction is the most common cause of persistent tearing in children under 1 year, with dacryocystoceles presenting with bluish discoloration over the nasolacrimal sac requiring urgent ophthalmology referral 3

Malignant Causes Requiring Biopsy

Gradual enlargement over weeks to months, central ulceration, irregular borders, eyelid margin destruction, loss of lashes, and chronic unilateral presentation unresponsive to standard therapy are red flags for malignancy. 4

• Sebaceous carcinoma presents with hard, non-mobile tarsal mass, yellowish discoloration, and chronic unilateral blepharoconjunctivitis unresponsive to treatment 4
• Basal cell carcinoma is the most common eyelid malignancy and can be misdiagnosed as benign lesions 4
• Conjunctival lymphoma presents as painless, pink "salmon patch" lesion with indolent fleshy swelling 4

Treatment Approach by Etiology

Medical Management for Corneal Edema

Topical sodium chloride 5% solution or ointment is first-line treatment to reduce corneal edema through hyperosmotic effect. 7

• Adjunctive hair dryer use provides temporary benefit 7
• Control intraocular pressure but avoid prostaglandin analogues if inflammation is present due to pro-inflammatory properties 7
• Do not use topical carbonic anhydrase inhibitors as first-line when endothelial dysfunction exists, as they interfere with the endothelial pump 7
• Control inflammation with topical corticosteroids after excluding infection 7

Bandage Contact Lens for Symptomatic Relief

• Use thin, high water content lenses with high oxygen diffusion coefficients for corneal edema with epithelial bullae 7
• Prescribe prophylactic broad-spectrum topical antibiotics to reduce infection risk 7
• Educate patients about infectious keratitis risk and need for immediate contact if symptoms develop 7
• Limit duration to short-term use, exchanging lenses periodically if long-term use is necessary 7

Surgical Options for Refractory Cases

• Phototherapeutic keratectomy provides pain relief through ablation of sub-basal nerve plexus but does not provide long-term visual rehabilitation 7
• Conjunctival flap for rapid healing, comfort, and inflammation reduction when visual rehabilitation is not the goal 7
• Amniotic membrane transplantation for epithelial healing 7
• Keratoplasty procedures for definitive treatment when visual potential exists 7

Treatment Algorithm for Eyelid Lesions

Presumed benign lesions should be managed with warm compresses, lid hygiene, and observation for 4-6 weeks, with biopsy if the lesion persists or recurs. 4

• For suspected malignancy, perform immediate biopsy with consultation regarding frozen sections and mapping for pagetoid spread 4
• Fresh tissue may be required for special stains such as oil red-O for lipid detection in sebaceous carcinoma 4

Critical Clinical Pitfalls

• Do not assume all periorbital edema is allergic or infectious—review medication history extending back months to years, as drugs like imatinib cause edema in the majority of patients 6
• Screen for C4 levels in recurrent angioedema without hives before assuming drug-related etiology, as this identifies hereditary causes 6
• Pure edematous swelling of eyelids should not immediately be blamed on contact allergy—exclude benign or malignant processes of eyelids, orbita, lacrimal duct, and paranasal sinuses 5
• Differentiate orbital from preseptal cellulitis immediately—orbital cellulitis requires CT imaging and parenteral antibiotics to prevent vision and life-threatening intracranial complications 2
• Marked asymmetry or unifocal recurrence demands biopsy, as these features significantly increase malignancy risk 4
• Dacryocystoceles require urgent ophthalmology referral due to high risk of complications, especially infection, unlike simple nasolacrimal duct obstruction which can be observed 3