What is the diagnosis and treatment for conjunctival chemosis?

Conjunctival Chemosis: Diagnosis and Treatment

What is Conjunctival Chemosis?

Conjunctival chemosis is swelling or edema of the conjunctiva caused by fluid accumulation in the subconjunctival space, presenting as a gelatinous or watery bulging of the conjunctiva that ranges from mild to severe. 1

The characteristic appearance is a gelatinous, watery bulging of the bulbar conjunctiva that can be dramatic and alarming to patients. 1

Diagnostic Approach

Identify the Underlying Cause

The key to managing chemosis is determining the underlying etiology, as chemosis itself is a sign rather than a diagnosis. The most common causes include:

Infectious Etiologies

• Viral conjunctivitis presents with chemosis, watery discharge, follicular reaction of the inferior tarsal conjunctiva, and preauricular lymphadenopathy 2, 1
• Bacterial conjunctivitis shows chemosis with purulent discharge 2, 1
• Gonococcal conjunctivitis is an emergency—presents with marked eyelid edema, severe purulent discharge, and can cause corneal perforation within 24-48 hours 2, 3
• Chlamydial conjunctivitis demonstrates follicular conjunctivitis with distinctive follicles on the bulbar conjunctiva and semilunar fold 2, 3

Allergic/Immune-Mediated

• Allergic conjunctivitis causes chemosis with itching, watery or mucoid discharge, and papillary reaction 1
• Graft-versus-host disease presents with bilateral chemosis and conjunctival injection 2, 1

Systemic/Medication-Related

• Thyroid eye disease shows chemosis with upper-eyelid laxity and eyelid imbrication 2, 1
• Dupilumab-associated ocular surface disease causes bilateral chemosis with follicular, papillary, or cicatrizing changes 2, 1
• Medication-induced chemosis occurs especially with preservatives in topical medications 2, 1

Mechanical/Structural

• Contact lens wear can cause chemosis from mechanical irritation or hypersensitivity 1
• Chronic localized conjunctival chemosis (CLCC) is diagnosed when localized conjunctival edema persists for ≥6 months without definitive inflammation, resulting from scarring and structural alteration of conjunctival lymphatics 4

Critical Examination Steps

Always examine the cornea with fluorescein staining in any case with chemosis to detect early corneal involvement, particularly in purulent conjunctivitis. 3

Look for these specific clinical features:

• Discharge type: Watery suggests viral/allergic 1; purulent indicates bacterial 1; mucopurulent suggests chlamydial 2
• Follicular vs papillary reaction: Follicles suggest viral or chlamydial infection 2; papillae indicate allergic etiology 1
• Preauricular lymphadenopathy: Strongly suggests viral etiology 2, 1
• Eyelid edema and erythema: Common in viral and allergic cases 2, 1
• Corneal involvement: Check for infiltrates, ulcers, or epithelial defects 2, 3

Treatment Algorithm

Acute Chemosis (Days to Weeks Duration)

For Viral Conjunctivitis

• Supportive care only—most cases are self-limited and resolve within 5-14 days 2, 1
• Cold compresses and artificial tears for symptom relief
• Monitor for progression to epidemic keratoconjunctivitis with subepithelial infiltrates 3
• Critical pitfall: Pseudomembranes are associated with higher rates of severe sequelae including conjunctival scarring, symblepharon, and keratitis 2, 3

For Allergic Conjunctivitis

• Topical antihistamines and mast cell stabilizers
• Topical steroids for severe cases (e.g., loteprednol etabonate)—monitor for elevated intraocular pressure 5
• For severe refractory cases: Topical adrenaline (1:1000) is effective when conservative therapies fail and can avoid invasive intervention 6

For Bacterial Conjunctivitis

• Topical broad-spectrum antibiotics (fluoroquinolones or aminoglycosides)
• If gonococcal suspected: Immediate systemic antibiotics (ceftriaxone 1g IM/IV) plus topical therapy—this is an emergency 2, 3
• If chlamydial suspected: Systemic antibiotics (azithromycin or doxycycline) required 2, 3

For Medication-Induced Chemosis

• Discontinue or switch the offending medication
• Consider preservative-free formulations 2, 1

Post-Surgical Chemosis

For severe chemosis after orbital or eyelid surgery where eyelids cannot close completely, perform early temporary tarsorrhaphy immediately. 7

• Early tarsorrhaphy (performed immediately when eyelids cannot close) resolves chemosis in 3.5 days versus 7.2 days with delayed intervention 7
• Remove sutures once conjunctiva subsides 7

Chronic Localized Chemosis (≥6 Months)

If localized conjunctival edema persists for ≥6 months without signs of active inflammation, consider chronic localized conjunctival chemosis (CLCC). 4

• Perform conjunctival biopsy to confirm diagnosis—shows chronic inflammation or lymphangiectasia 4
• This condition results from irreversible scarring of conjunctival lymphatics 4
• Treatment options are limited; surgical debulking may be considered for exposed lacrimal caruncle causing persistent chemosis 8

High-Risk Situations Requiring Immediate Action

Any purulent conjunctivitis in a neonate is an emergency until gonococcal and chlamydial causes are ruled out—gonococcal infection can lead to septicemia, meningitis, and death. 3

Consider sexual abuse in children presenting with gonococcal or chlamydial conjunctivitis. 3

Immunocompromised patients are at higher risk for severe complications and atypical presentations—maintain heightened vigilance. 3

Common Pitfalls to Avoid

• Never assume chemosis is benign without examining the cornea—corneal involvement dramatically changes management and prognosis 3
• Do not use topical steroids in suspected infectious keratitis—this can worsen herpes simplex keratitis and lead to corneal perforation 2
• Do not delay systemic antibiotics in gonococcal conjunctivitis—topical therapy alone is insufficient 2, 3
• Recognize that chemosis can be the presenting sign of serious systemic disease including thyroid eye disease, graft-versus-host disease, or vasculitis 2, 1