A patient presents with a swollen eye; how should I evaluate and manage it?

Evaluation and Management of a Swollen Eye

Immediately assess for vision-threatening conditions by checking visual acuity, pupil reactivity, presence of pain with eye movements, proptosis, and restricted extraocular movements—these red flags determine whether the patient needs emergency ophthalmology referral within 24 hours or can be managed with routine care. 1, 2

Critical Red Flags Requiring Emergency Ophthalmology Referral (Within 24 Hours)

Perform these assessments first to identify vision-threatening emergencies:

• Visual acuity changes or vision loss 1, 3, 4
• Severe eye pain or pain with eye movements (suggests orbital cellulitis) 1, 5, 3
• Proptosis (forward displacement of the globe) 2, 5
• Restricted extraocular movements or ophthalmoplegia (distinguishes orbital from preseptal cellulitis) 1, 5, 3
• Mid-dilated or poorly reactive pupil (suggests acute angle-closure glaucoma or uveitis) 1, 3
• Severe photophobia with blurred vision (indicates possible keratitis or anterior uveitis) 1, 4
• Purulent discharge with fever (suggests infectious process) 1
• Evidence of corneal damage on examination 1

If any of these red flags are present, do not initiate treatment—refer immediately to ophthalmology. 1

Determine if Swelling is Unilateral or Bilateral

Unilateral Swelling

Suggests localized ocular or periocular pathology:

• Hordeolum (stye): Well-defined tender mass at lid margin 5, 3
• Chalazion: Non-tender mass within mid-portion of eyelid 5
• Preseptal cellulitis: Eyelid swelling with erythema but normal vision and extraocular movements 5, 3
• Orbital cellulitis: Eyelid swelling with pain, restricted eye movements, proptosis, and vision changes 1, 5, 3
• Contact dermatitis: Erythematous irritation with identifiable allergen exposure 5
• Herpes zoster ophthalmicus: Vesicular rash in dermatomal distribution 5

Bilateral Swelling

Indicates systemic disease rather than localized ocular pathology:

• Assess timing: Worse upon waking suggests fluid redistribution; persistent suggests systemic pathology 2
• Check for systemic edema: Jugular venous distension, S3 gallop, lower extremity edema, ascites 2
• Order initial labs: Basic metabolic panel (renal function), liver function tests, thyroid function tests, urinalysis with protein quantification, complete blood count 2
• Consider BNP if cardiac symptoms present (>100 pg/mL suggests heart failure) 2

CT imaging is NOT routinely indicated for bilateral periorbital edema unless there is trauma, unilateral involvement, proptosis, vision changes, or suspected orbital cellulitis. 2

Management Algorithm for Patients WITHOUT Red Flags

Initial Conservative Management

• Warm compresses applied to affected eyelid 1
• Preservative-free lubricants for symptomatic relief 1
• Lid hygiene with gentle cleaning of lid margins 1
• Avoid empiric topical steroids, which can worsen infectious keratitis or mask serious conditions 1

Follow-Up Timing

• Routine ophthalmology referral within 4 weeks if mild-to-moderate symptoms persist or if unresponsive to initial treatment after 1 week 1
• Counsel patients that symptoms can be improved but rarely eliminated completely, and compliance with treatment is essential 1

Common Pitfalls to Avoid

• Assuming bilateral periorbital edema is benign without evaluating for systemic disease (renal, cardiac, hepatic, thyroid) 2
• Overlooking medication-induced causes such as delayed hypersensitivity reactions to medications 2
• Initiating treatment before ophthalmology evaluation when red flags are present 1
• Failing to differentiate preseptal from orbital cellulitis—orbital cellulitis has restricted eye movements and vision changes, preseptal does not 5, 3
• Delaying ophthalmologic referral when vision changes are present, which can lead to permanent vision loss 2, 6

Special Considerations for Specific Conditions

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (if suspected based on systemic findings)

If patient has concurrent skin sloughing or mucosal involvement:

• Immediate ophthalmology consultation with daily review during acute illness 7
• Apply lubricant every 2 hours (nonpreserved hyaluronate or carmellose drops) 7
• Daily ocular hygiene by ophthalmologist or trained nurse to remove debris and prevent adhesions 7
• Topical dexamethasone 0.1% twice daily may reduce ocular surface damage (supervised by ophthalmologist) 7
• Broad-spectrum topical antibiotic (moxifloxacin four times daily) if corneal staining present 7