What is the treatment for an adult patient with no significant medical history presenting with soft tissue swelling under the eye?

Treatment of Soft Tissue Swelling Under the Eye

The most critical first step is to immediately distinguish between preseptal cellulitis (infection anterior to the orbital septum) and orbital cellulitis (infection posterior to the septum), as orbital cellulitis is a medical emergency requiring immediate hospitalization with IV antibiotics, while preseptal cellulitis can often be managed with oral antibiotics and close outpatient monitoring. 1

Immediate Assessment: Red Flags Requiring Emergency Intervention

You must evaluate for these specific signs of orbital cellulitis that mandate immediate hospitalization 1, 2:

• Proptosis (eye bulging forward) 1
• Restricted or painful extraocular movements 1, 2
• Decreased visual acuity 1
• Relative afferent pupillary defect (RAPD) 2
• Chemosis (conjunctival swelling) 1
• Fever, especially >102°F 2

If ANY of these signs are present, obtain immediate CT or MRI imaging of the orbits and sinuses—imaging is mandatory when orbital involvement is suspected. 1

Diagnostic Workup

Document these specific examination findings 1:

• Visual acuity measurement in both eyes 1
• Extraocular movement assessment in all directions 1
• Pupillary response evaluation including checking for RAPD 1
• Degree of eyelid edema and whether it extends beyond the eyelid margin 1
• Presence of chemosis 1
• Check for preauricular lymphadenopathy (suggests viral conjunctivitis) 3
• Assess for purulent nasal discharge or headache (suggests occult sinusitis) 4

Obtain blood cultures and consider conjunctival cultures before starting antibiotics if infection is suspected. 1

Treatment Algorithm Based on Diagnosis

For Orbital Cellulitis (Emergency)

Immediate hospitalization with IV broad-spectrum antibiotics covering Gram-positive organisms, Gram-negative organisms, and MRSA. 1 The specific antibiotic choice should be guided by local antimicrobial resistance patterns. 1

• Daily ophthalmologic examination during acute illness 1
• Serial imaging if no clinical improvement within 48-72 hours 1
• Consider endoscopic sinus surgery if sinusitis is identified as the source 2, 4

For Preseptal Cellulitis (Non-Emergency)

Oral antibiotics with close outpatient monitoring and mandatory re-evaluation within 24-48 hours to confirm improvement. 1

Instruct the patient to return immediately if any of these develop 1:

• Vision changes
• Eye movement restriction
• Increased pain

For Non-Infectious Causes

If infection is ruled out and the swelling is due to benign causes (trauma, allergic reaction, subconjunctival hemorrhage):

Symptomatic management with cold compresses applied for 20-30 minutes per session using a barrier (thin towel) between the cold source and skin to prevent cold injury. 3, 1 The greatest tissue cooling is achieved using a bag filled with ice and water surrounded by a damp cloth. 3

Artificial tears for mild irritation if conjunctival involvement is present. 3

Patient education that benign periorbital swelling typically resolves within 1-2 weeks without specific treatment. 3

Critical Pitfalls to Avoid

Never use topical corticosteroids before ruling out infection—they can mask signs of corneal infection and worsen outcomes. 1, 5 Only consider topical corticosteroids once infection is controlled and only under ophthalmologist supervision. 1

Do not underestimate eyelid abscesses—they may indicate occult sinusitis requiring both incision/drainage and functional endoscopic sinus surgery. 4 Two patients in one case series had small bony defects between infected frontal sinuses and the eyelid. 4

Avoid misdiagnosing orbital cellulitis as preseptal cellulitis—delay in diagnosis can lead to vision-threatening and life-threatening intracranial complications. 2

Special Populations

For immunocompromised patients, pursue aggressive ophthalmologic evaluation regardless of initial appearance, as they are at higher risk for rapid progression and atypical organisms. 1

For patients on anticoagulation therapy who develop subconjunctival hemorrhage with periorbital swelling, continue anticoagulation without interruption—isolated subconjunctival hemorrhage does not meet criteria for stopping therapy. 3 Do not administer reversal agents. 3

When to Consider Alternative Diagnoses

If swelling is recurrent, progressive, and interfering with vision despite treatment, consider 6, 7:

• Orofacial granulomatosis (presents with dense infiltrates and severe periorbital edema, requires biopsy and localized anti-inflammatory treatment) 7
• Inflammatory conditions requiring systemic workup 6
• Occult tumors requiring imaging 6