What causes swollen eye bags?

Swollen Eye Bags: Causes and Clinical Approach

Primary Etiologies

Swollen eye bags result from six major underlying mechanisms: aging-related fat prolapse, fluid retention, allergic inflammation, chronic eyelid disorders, systemic disease manifestations, and rarely, malignancy. 1, 2

Structural and Age-Related Causes

• Fat prolapse and atrophy represent the most common structural causes, where orbital fat herniates anteriorly through weakened septae or atrophies with age, creating visible bulging or hollowing 2
• Senescent or congenital bone deficiency of the midface and orbital rim contributes to inferior displacement of periorbital tissues 2
• Eyelid laxity from aging or genetic predisposition allows tissues to sag, particularly in floppy eyelid syndrome where the upper eyelid easily everts and demonstrates horizontal lid laxity with associated upper eyelid edema 1

Inflammatory and Allergic Conditions

• Atopic keratoconjunctivitis causes chronic eyelid and periorbital skin inflammation with conjunctival hyperemia and edema, characterized by papillary tarsal conjunctival reaction 1
• Vernal keratoconjunctivitis predominantly affects children and young adults, causing severe eyelid swelling and ptosis with thick pseudomembranous structures 1, 3
• Giant papillary conjunctivitis presents with laterality associated with contact lens wear pattern, featuring papillary hypertrophy of superior tarsal conjunctiva and mucoid discharge causing lid swelling 1
• Contact allergic blepharoconjunctivitis from cosmetics, eye medications, or eyeglass frame materials causes periorbital dermatitis affecting areas where frames contact the face 4, 3

Infectious Causes

• Preseptal cellulitis presents with diffuse eyelid swelling, erythema, and warmth without vision changes or ophthalmoplegia 5
• Hordeolum (stye) appears as a well-defined painful mass at the lid margin 6, 5
• Chalazion manifests as a mass within the midportion of the lid from meibomian gland obstruction 6, 5

Systemic Disease Manifestations

• Thyroid eye disease (most often Graves' disease) causes bilateral but asymmetric edema and erythema of periorbital tissues and conjunctivae, with upper eyelid retraction, proptosis, and extraocular muscle enlargement 1
• Rosacea-associated inflammation produces bilateral chronic blepharitis with eyelid margin telangiectasias, meibomian gland dysfunction, and inferior involvement 1

Serious Conditions Requiring Urgent Evaluation

• Orbital cellulitis distinguished from preseptal cellulitis by presence of painful/impaired eye movements, proptosis, vision changes, or ophthalmoplegia—requires emergent hospitalization, contrast-enhanced CT, and IV antibiotics 7, 5
• Sebaceous carcinoma masquerades as chronic unilateral blepharoconjunctivitis resistant to treatment, appearing as a hard nodular nonmobile mass with yellowish discoloration or focal lash loss 1, 7

Diagnostic Algorithm

Red Flags Requiring Immediate Action

• Check for proptosis, painful/impaired eye movements, fever, vision loss, or systemic toxicity—if any present, immediate hospitalization with contrast-enhanced CT orbits/sinuses, IV antibiotics, and urgent ophthalmology/ENT/ID consultation required 7
• Perform fluorescein staining in every case to detect corneal involvement not clinically apparent 7
• Unilateral chronic presentation unresponsive to treatment warrants biopsy to rule out malignancy 7

Key History Elements

• Duration and onset pattern (acute vs. subacute vs. chronic) 5
• Presence of pain, itching, discharge character, vision changes 1
• Contact lens wear history including type, hygiene practices, and wearing schedule 1
• Exposure to allergens including cosmetics, eye medications, eyeglass materials 4, 3
• Systemic symptoms suggesting thyroid disease (weight changes, tachycardia, fatigue), autoimmune conditions, or infection 1, 7

Physical Examination Priorities

• Assess eyelid margin for telangiectasias, meibomian gland dysfunction, abnormal deposits at lash bases, or focal lash loss (ciliary madarosis suggesting malignancy) 1, 7
• Evaluate extraocular motility for restriction or weakness 7
• Examine for papillary hypertrophy of tarsal conjunctiva by everting eyelids 1
• Test eyelid laxity using snap test, push test, and lift test to assess structural integrity 2

Common Pitfalls to Avoid

• Never dismiss vision loss as "just dermatitis"—urgent ophthalmology evaluation required 7
• Do not treat presumed preseptal cellulitis with oral antibiotics alone if vision is decreased—this suggests orbital involvement requiring hospitalization 7
• Always perform fluorescein staining even if cornea appears clear on gross examination 7
• Biopsy any chronic unilateral eyelid lesion resistant to treatment to rule out sebaceous carcinoma or other malignancy 1, 7
• Consider dupilumab-related ocular surface disorders in patients with atopic dermatitis on biologic therapy, as most cases develop within first 4 months but can occur later 1