What is the management and potential cause of a patient presenting with a swollen left eye and drainage?

Management and Causes of Swollen Left Eye with Drainage

The immediate priority is to distinguish between preseptal cellulitis (which can be managed with oral antibiotics) and orbital cellulitis (which requires immediate hospitalization with IV antibiotics), as missing orbital involvement can be life-threatening. 1

Critical Initial Assessment

Perform an urgent evaluation for red flags indicating orbital cellulitis:

• Proptosis (eye bulging forward)
• Impaired or painful extraocular movements
• Decreased visual acuity
• Ophthalmoplegia
• Severe headache or photophobia 1

If ANY of these signs are present, immediate hospitalization with IV antibiotics is mandatory. 1

Differential Diagnosis by Age and Presentation

In Infants and Neonates

Any purulent conjunctivitis in a neonate is an emergency until gonococcal causes are ruled out, as this can cause corneal perforation within 24-48 hours, septicemia, meningitis, and death. 2

Key considerations in infants:

• Gonococcal conjunctivitis: Severe, rapidly reaccumulating purulent discharge with marked eyelid swelling requiring immediate systemic antibiotics 2
• Chlamydial conjunctivitis: Follicular conjunctivitis requiring systemic antibiotics, not just topical treatment 2
• Herpes simplex virus: Presence of eyelid vesicles is pathognomonic and requires immediate ophthalmology referral 2
• Nasolacrimal duct obstruction with dacryocystitis: Erythema, swelling, warmth, and tenderness over the lacrimal sac requiring urgent ophthalmology referral due to high risk of periorbital cellulitis, meningitis, and sepsis 3

In Children and Adults

Bacterial conjunctivitis is the most common cause, presenting with mucopurulent discharge, eyelid swelling, and conjunctival injection. 4, 2

Other important causes:

• Preseptal cellulitis: Eyelid swelling, erythema, and warmth without proptosis or impaired extraocular movements 1, 2
• Viral conjunctivitis (adenoviral): Watery discharge, preauricular lymphadenopathy, follicular reaction 4
• Allergic conjunctivitis: Bilateral itching, chemosis, watery discharge (less likely with unilateral presentation)

Management Algorithm

Step 1: Rule Out Orbital Cellulitis

Obtain contrast-enhanced CT scan of orbits and paranasal sinuses if:

• Any clinical suspicion of orbital involvement
• Severe headache or photophobia
• Neurologic findings
• Sinusitis-associated cases, especially ethmoid sinusitis in children under 5 years 1

Step 2: Assess for Corneal Involvement

Perform fluorescein staining to detect corneal involvement, which requires immediate ophthalmology referral. 2

Step 3: Determine Treatment Based on Diagnosis

For Preseptal Cellulitis (Children)

Oral antibiotics are appropriate ONLY when ALL criteria are met:

• Eyelid less than 50% closed
• No proptosis or visual changes
• No impairment of extraocular movements
• No systemic signs of severe infection
• Reliable follow-up available within 24-48 hours 1

First-line oral antibiotic: High-dose amoxicillin-clavulanate 80-90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses 1

Alternative for penicillin allergy (non-type 1): Cefdinir, cefuroxime, or cefpodoxime 1

Avoid: Trimethoprim/sulfamethoxazole or azithromycin due to high resistance rates 1

For Bacterial Conjunctivitis

Mild cases in immunocompetent adults are self-limited and may not require antibiotics, though treatment shortens morbidity. 4

For moderate to severe cases or when treatment is desired:

• Broad-spectrum topical antibiotic for 5-7 days 4
• Moxifloxacin 0.5% ophthalmic solution: One drop in affected eye 3 times daily for 7 days 5
• Alternative: Any broad-spectrum topical antibiotic (choice based on convenience/cost) 4

In presence of corneal fluorescein staining or frank ulceration: Administer broad-spectrum topical antibiotic as prophylaxis (e.g., moxifloxacin drops four times daily) 4

For Viral Conjunctivitis

No antibiotics are indicated, as they are ineffective for viral infections. 6

Management includes:

• Topical lubricants for comfort 4, 6
• Cold compresses for symptomatic relief 6
• Patient education about contagiousness (avoid contact for 10-14 days) 4
• Topical corticosteroids may be considered for severe cases with marked chemosis or membranous conjunctivitis under close supervision 6

Critical Follow-Up Requirements

For patients started on oral antibiotics for preseptal cellulitis:

• Mandatory reassessment within 24-48 hours 1
• Failure to improve or worsening symptoms requires immediate hospitalization with IV antibiotics 1

For bacterial conjunctivitis:

• Follow-up within 1 week if symptoms persist 4
• Examine with slit-lamp biomicroscopy and fluorescein staining when clinically indicated 5

Important Caveats

Do not allow contact lens wear in patients with signs or symptoms of bacterial conjunctivitis. 5

Watch for superinfection: Prolonged antibiotic use may result in overgrowth of non-susceptible organisms including fungi, requiring discontinuation and alternative therapy 5

Hypersensitivity reactions: Serious and occasionally fatal anaphylactic reactions have been reported with systemic quinolones; discontinue immediately if allergic reaction occurs 5