What is the management for a 16-year-old patient presenting with left upper eyelid swelling?

Management of Left Upper Eyelid Swelling in a 16-Year-Old

Immediately assess for orbital cellulitis by examining for proptosis, restricted or painful extraocular movements, vision changes, or severe pain with eye movement—if any are present, hospitalize for IV antibiotics and urgent imaging. 1, 2

Initial Assessment and Red Flag Identification

The first priority is distinguishing preseptal from orbital cellulitis, as this determines whether outpatient or emergent inpatient management is required:

Critical Red Flags Requiring Immediate Hospitalization 1, 2:

• Proptosis (eye bulging forward)
• Restricted or painful extraocular movements
• Decreased visual acuity
• Severe pain, especially with eye movement
• Fever with systemic toxicity
• Severe headache or altered mental status

If any red flags are present, obtain contrast-enhanced CT of orbits/sinuses immediately, start IV antibiotics covering Staphylococcus aureus and Streptococcus species, and consult ophthalmology, otolaryngology, and infectious disease urgently. 1

Examination Technique

Perform a focused examination including: 2

• Visual acuity testing
• Extraocular movement assessment (pain with movement is critical)
• Pupillary examination
• Evert the upper eyelid to examine the tarsal conjunctiva for papillary hypertrophy or follicles
• Fluorescein staining to rule out corneal involvement
• Palpate for focal tenderness or nodules

Most Likely Diagnoses and Management

Preseptal Cellulitis (If No Orbital Signs Present)

For mild preseptal cellulitis (eyelid <50% closed), start high-dose oral amoxicillin-clavulanate with daily follow-up until definite improvement. 1

• Apply warm compresses to reduce swelling 1
• Follow up within 24-48 hours to ensure no progression 2
• Hospitalize for IV antibiotics if no improvement in 24-48 hours or if infection progresses 1
• Immediate referral if any signs of orbital involvement develop 2

Hordeolum (Stye)

If there is acute, painful, localized swelling at the eyelid margin with focal tenderness: 2

• Apply warm compresses for 5-10 minutes once or twice daily 3, 1
• Perform gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01% after compresses 3, 1
• Gentle massage to express gland contents 1
• Second-line: topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins once daily or at bedtime 3, 1

Chalazion

If there is a firm, non-tender nodule within the tarsal plate: 2

• Warm compresses and observation for 4-6 weeks 2
• Gentle eyelid massage to express meibomian glands 3
• Refer to ophthalmology if persistent or recurrent after 4-6 weeks 2

Blepharitis-Related Swelling

If chronic eyelid inflammation with crusting or meibomian gland dysfunction: 3

• Daily warm compresses for several minutes to soften secretions 3
• Eyelid cleansing with hypochlorous acid 0.01% or diluted baby shampoo 3
• Vertical eyelid massage to express meibomian secretions 3
• Topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins at bedtime for several weeks 3
• For persistent symptoms: consider oral doxycycline (avoid tetracyclines in pregnancy/young children) 3

Contact Lens-Related Causes

If the patient wears contact lenses: 3, 1

• Discontinue contact lens wear immediately until resolution 3, 1
• Switch to daily disposables or increase replacement frequency 1
• Use preservative-free solutions 1
• Consider topical mast-cell stabilizers for giant papillary conjunctivitis 1

Important Clinical Pitfalls

Never start topical corticosteroids before ruling out infection, as this may worsen infectious processes or mask accurate diagnosis. 1

For patients with advanced glaucoma, counsel about avoiding aggressive eyelid pressure during warm compress application, as this may increase intraocular pressure. 3

If bandage contact lens is used for any reason (e.g., bullous keratopathy), use prophylactic topical broad-spectrum antibiotics and warn about infectious keratitis risk. 3

When to Refer to Ophthalmology

Urgent same-day referral: 1, 2

• Any signs of orbital cellulitis
• Vision changes
• Severe pain
• Suspected malignancy (irregular, ulcerated, or bleeding lesion)

Routine referral: 2

• Chalazion persistent after 4-6 weeks of conservative management
• Recurrent hordeola or chalazia
• Chronic blepharitis not responding to initial management

Follow-Up

For preseptal cellulitis treated as outpatient: mandatory follow-up within 24-48 hours to assess for progression. 1, 2

For hordeolum/chalazion: follow up in 2-4 weeks if symptoms persist despite conservative management. 2