What is the appropriate treatment and management for a patient with eye swelling, considering their demographic, medical history, and potential underlying causes such as allergies or infection?

Eye Swelling: Diagnostic and Treatment Approach

The initial priority is to rapidly distinguish between benign allergic/inflammatory causes versus sight-threatening conditions requiring urgent ophthalmology referral, with immediate treatment directed by the underlying etiology identified through targeted history and examination.

Immediate Assessment Priorities

Critical Red Flags Requiring Urgent Ophthalmology Referral

• Vision changes or decreased visual acuity - may indicate corneal involvement, uveitis, or acute angle closure 1
• Severe eye pain - suggests acute angle closure, corneal pathology, or severe inflammation 1
• Corneal edema or opacity on examination - requires same-day evaluation 1
• Pupillary abnormalities (mid-dilated, non-reactive, or irregular) - indicates acute pathology 1
• Conjunctival injection with discharge - may represent infectious conjunctivitis requiring specific antimicrobial therapy 1
• Proptosis, restricted eye movements, or diplopia - suggests orbital involvement requiring urgent imaging 1

Essential History Elements

• Onset timing: Acute (hours) suggests allergic reaction or infection; gradual (days-weeks) suggests inflammatory or neoplastic process 1, 2
• Unilateral versus bilateral: Unilateral more concerning for infection, malignancy, or focal inflammation 1, 2
• Recent medication exposures: Topical ophthalmic drops (tropicamide, phenylephrine, anesthetics) are common culprits 3, 4, 5
• Associated symptoms: Itching favors allergy; pain with vision loss suggests corneal or intraocular pathology 1, 6
• Contact lens use: Raises concern for giant papillary conjunctivitis or infectious keratitis 1, 6

Targeted Physical Examination

• Visual acuity testing in each eye - any decrease requires ophthalmology evaluation 1
• Pupil examination for reactivity and relative afferent pupillary defect 1
• Slit-lamp biomicroscopy (if available) to assess for corneal edema, anterior chamber inflammation, or conjunctival pathology 1
• Intraocular pressure measurement - elevated IOP can cause corneal edema 1
• Eyelid examination for vesicular lesions (HSV), nodules (malignancy), or eczematous changes (contact dermatitis) 1, 4

Treatment Algorithm by Etiology

Allergic Causes (Most Common in Bilateral Cases)

For simple allergic conjunctivitis without vision changes:

• Topical antihistamines or mast cell stabilizers as first-line therapy 6
• Cold compresses and artificial tears for symptomatic relief 6
• Oral antihistamines for systemic allergic symptoms 6
• Discontinue suspected allergen (cosmetics, eye drops, contact lenses) 6, 4

For contact allergic blepharoconjunctivitis:

• Identify and remove causative agent - commonly cosmetics, ophthalmic medications (preservatives), or topical anesthetics 4, 5
• Topical corticosteroids for eyelid eczema in perennial cases requiring longer therapy 6
• Consider patch testing if allergen unclear 4

For acute drug hypersensitivity (e.g., tropicamide, anesthetics):

• Immediate discontinuation of offending agent 3, 5
• Intravenous hydrocortisone for severe reactions with rapid progression 3
• Topical steroids for localized inflammation 3
• Skin testing to identify specific allergen and safe alternatives 5

Corneal Edema with Eyelid Swelling

Medical management (first-line):

• Topical sodium chloride 5% solution or ointment to reduce corneal edema through hyperosmotic effect 1, 7, 8
• IOP reduction if elevated - avoid prostaglandin analogues if inflammation present due to pro-inflammatory properties 1, 7
• Avoid topical carbonic anhydrase inhibitors as first-line when endothelial dysfunction suspected - they interfere with endothelial pump 1, 7, 8
• Topical corticosteroids after excluding infection to control inflammation 1, 7

For symptomatic bullous keratopathy:

• Bandage contact lens (thin, high water content, high Dk) for pain relief 1, 7
• Prophylactic broad-spectrum topical antibiotics when bandage lens used to prevent infectious keratitis 7
• Patient education about infection risk and need for immediate contact if redness, pain, or photophobia develops 7

Infectious Conjunctivitis

Viral (adenoviral) conjunctivitis:

• Self-limited - improves within 5-14 days without specific treatment 1
• Supportive care with cold compresses and artificial tears 1
• Infection control measures - highly contagious, especially in school settings 1

Herpes simplex virus:

• Urgent ophthalmology referral for dendritic keratitis or corneal involvement 1
• Antiviral therapy (topical or systemic) as directed by ophthalmologist 1

Bacterial conjunctivitis:

• Topical broad-spectrum antibiotics (fluoroquinolone or aminoglycoside) 1
• Ophthalmology referral if severe, unilateral, or not improving within 48 hours 1

Inflammatory/Autoimmune Uveitis

For grade 2-3 uveitis with eyelid swelling:

• Hold immunotherapy if drug-induced (checkpoint inhibitors) 1
• Ophthalmology referral within 2 days before initiating treatment 1
• Coordinate treatment with ophthalmologist - typically topical steroids, cycloplegic agents, potentially systemic steroids 1
• Rule out infection first - starting steroids before eye exam may worsen infectious causes (herpetic keratitis) or mask diagnosis 1

For grade 4 (severe vision loss):

• Permanently discontinue causative agent if drug-induced 1
• Urgent ophthalmology referral (preferably uveitis specialist) before treatment initiation 1
• Systemic steroids in addition to local therapy as recommended by specialist 1

Common Pitfalls to Avoid

• Do not start corticosteroids before ophthalmology examination if infection possible - may worsen herpetic keratitis or mask accurate diagnosis 1
• Do not use prostaglandin analogues for IOP control when inflammation is contributing factor - they have pro-inflammatory properties 1, 7
• Do not dismiss persistent unilateral eyelid swelling - must exclude malignancy (sebaceous carcinoma, lymphoma, melanoma) with biopsy if chronic and unresponsive 1, 2
• Do not assume anti-VEGF allergy without testing all procedural medications - local anesthetics are often the culprit 5
• Do not use bandage contact lenses without prophylactic antibiotics - significantly increases infectious keratitis risk 7

When Conservative Management Fails

For refractory corneal edema with persistent symptoms:

• Phototherapeutic keratectomy (PTK) for pain relief through nerve ablation - does not provide visual rehabilitation 7
• Conjunctival flap for rapid healing and comfort when vision not salvageable 7
• Keratoplasty (endothelial or penetrating) for definitive treatment when visual potential exists 7

For persistent eyelid swelling despite treatment:

• Biopsy to exclude masquerade syndromes - lymphoma, sebaceous carcinoma, or other malignancies can mimic chronic inflammation 1, 2
• Systemic workup for autoimmune conditions (Sjögren's, IgG4-related disease, vasculitis) if bilateral and chronic 2