The Swollen Eyelids

The duty of the referring doctor is to differentiate conditions which do not require urgent ocular referrals from those which can be potentially sight-threatening.

The most common causes of  swollen eyelids are:

 
       
Chalazion

The eyelids contain many different glands which can become blocked and superinfected. The resulting condition is termed hordeolum.
 

Presentation:

  • redness, swelling, and pain in the eyelid 
  • they may be associated conjunctivitis and purulent discharge


Examination:

  • The visual acuity is normal unless the swelling is big and right in the centre of the upper lid which can distort vision through its mass effect on the cornea.
  • The swelling  may be at the base of an eyelash (sty or external hordeolum) or deep within the lid (meibomianitis or internal hordeolum)


Management:

  • Topical antibiotic such as chloramphenicol drop is instilled into the lower conjunctival sac four times a day.
  • If the lid swelling is extensive and severe, consider superimposed orbital cellulitis which require systemic antibiotics
  • Referrals are not neccessary as the conditions resolves within 

    • a few days.
  • Referred to the minor operating list if the swelling fails to resolve after one week. This is mostly seen in internal hordeolum in which a granuloma (chalazion) had developed. The treatment is incision and curretage.
Figure 1.
This patient has a right upper lid chalazion. Note the localized nature of the 
swelling. This can be treated with topical chloramphenicol by the GP. If  the 
swelling fails to resolve, refer the patient to the minor operating list for
incision and curettage

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Orbital cellulitis

This is a potentially sight-threatening condition and the patient should be referred to the ophthlamologists for further management. Sight loss may result from central retinal artery occlusion or optic nerve inflammation. In adults the most common infection are Staphylococcus aureus, Streptoccocus pyogenes or Streptoccus penumoniae. In children , it is often secondary to infection in the adjacent sinuses and Haemophilia influzae is an important pathogen.

Presentation:

  • Severe pain
  • Tense and red orbit with lid closure
  • Pyrexia 
Examination
  • Intense swelling of the lids
  • Proptosis
  • Congestion of the conjunctival and episcleral vessels
  • Chemosis (swollen conjunctiva)
  • Double vision may occur due to poor eye movement in 

    • a congested orbit.
Treatment:
  • Refer to the ophthalmologist within 24 hours.
  • Treatment require systemic antibiotics and analgesia.
Figure 1.
This child has a typical appearance of orbital cellulitis with swollen and tense right 
eyelid and difficulty in openin the eye. Treatment should involve admission with
intravenous antibiotics.
Figure 2.
This is the CT scan of a 7 year-old patient with a right orbital cellulitis. Note the 
presence of opacity in the right ethmoid sinus. The orbital cellulitis is caused by 
the spread of infection from ethmoid sinusitis.
 

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Herpes zoster ophthalmicus

This is caused by reactivation of herpes zoster virus in patient who previously had chickenpox. The eye is affected in 50% of zoster ophthalmicus and is increased in patients with involvement of the nasociliary nerve (rash at the tip of the nose). 

Presentation:

  • pain in the distribution of the ophthalmic nerve followed in a few days with vesicular eruption 
Examination
  • Vesicular rash affecting the scalps and lids
  • Vision may be reduced with ocular involvement (keratitis and anterior uveitis)
  • Swollen lids may make eye examination difficult
  • Ocular injections
  • Discharge from conjunctivitis


Management:

  • Oral acyclovir is useful in speeding up the resolution of the rash
  • Analgesia should be given as the condition is very painful
  • Conjunctivitis is common and does not require treatment
  • Referred to the ophthalmologists within  24 hours from seeing for exclusion of ocular involvement such as iritis and keratitis.

 
Figure 1.
This 78 year-old woman presented to the GP with a 3 day-history of right sided headache. 
The GP suspected giant cell arteritis but her ESR was normal. Within 24 hours, she 
developed this vesicular rash typical of herpes zoster ophthlamicus. Note the distribution
of the rash which corresponds to the dermatome of the ophthalmic nerve. She was referred 
to the eye casualty and was found to have anterior uveitis. She was treated with topical 
steroid and mydriatic drops.
 
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Acute dacryocystitis

This is caused by inflammation of the lacrimal sac. It is often associated with obstruction of the nasolacrimal duct with watering of the eye. Infection are often due to streptococcus and staphylococcus.

Presentation:

  • Painful swelling at the nasal side of the lower lid. 
Examination:
  • Visual acuity is normal.
  • The swelling is tense and  tender to touch
  • In severe cases, the whole of the lower lid may be swollen due to superimposed cellulitis
Management:
  • Refer the patient to the ophthalmologists within 24 hours.
  • High dose systemic antibiotic is required either orally or by intravenous.
  • Incision of the swelling should be avoided as this can cause fistula formation
  • Most patient will require dacryocystorhninostomy (an artificial passage is created between the lacrimal sac and the nasal cavity to bypass the blockage)  when the acute episode settle.

    •  
Figure 1.
This patient presented with a swellon and painful left lower lid. Note the location of the
swelling which is diagnostic of acute dacryocystitis. High dose oral antibiotics were given. 
When the swelling settled, a dacryorhinostomy was performed to prevent recurrence.