Tender and swollen eyelids after a viral infection

The question:

A 17-year-old female presents at your practice with a sudden swollen lid on her right eye. The eyelid is tender to touch, and her eye is watering continually. The left eye is normal. She had a cold recently, and the symptoms are continuing. How would you manage this patient? 

OT’s panel says...

Ankur Trivedi: I would ask more about the patient’s recent general health issues, and whether there have there been any similar occurrences previously. Although perception of pain can be variable between patients, asking for the level of pain or discomfort to be rated on a one to 10 scale would also be helpful.

Questions I would then ask include:

• What is the magnitude of the swelling, and is it present on the whole lid or just part of it?
• How far from the lid margin is the affected area?
• Is there associated erythema, and if so, how far does that extend?
• Is the vision affected, and if so by how much?

The scenario does not state whether the upper or lower lid is affected, but acute dacryocystitis would affect the lower lid and/or the area anterior to the lacrimal sac.

The use of the word ‘sudden’ makes me think this is a case which is less than 24 hours old, so I would want to ask for an exact timescale. If it is as sudden as suggested, something chronic like a chalazion is less likely. I would also check whether there is any ptosis or proptosis.

My working list of differentials would be:

• Conjunctivitis (various potential aetiologies)
• Hordeolum (internal or external)
• Preseptal cellulitis
• Acute dacryocystitis
• Orbital cellulitis.

To help rule out the more serious side of things, for instance orbital cellulitis, I would want to check:

• Visual acuity, with pinhole if required. Reduction makes orbital cellulitis more likely, however in cases of hordeolum the visual acuity can be reduced if there is direct pressure on the cornea due to the lid swelling
• Motility, which if painful and/or restricted makes orbital cellulitis more likely
• Pupil reactions, which if affected makes orbital cellulitis more likely
• Monocular colour vision, which if reduced, especially against the fellow eye, makes orbital cellulitis more likely
• Temperature, to rule out pyrexia – fever or generally being unwell points toward preseptal or orbital cellulitis.

Ceri Smith-Jaynes: My immediate thoughts are around internal hordeolum or preseptal cellulitis; I would want to examine her the same day and rule out orbital cellulitis.

I’ll add a couple to Ankur’s list of differential diagnoses: sometimes, a swollen lid can be due to a corneal scratch or foreign body on the tarsal conjunctiva. We always ask about contact lens wear in the triage process for these presentations; this could be a contact lens-related infection.

If I see an external or internal hordeolum in her lid, I’ll make sure to look at the other lids and the other eye for clues about blepharitis. The causative organism is probably bacterial, so we need to start good lid hygiene measures and consider a topical antibiotic for the lid margins.

If it’s really red and angry, I’m not a big fan of adding a lot of heat. College of Optometrists Guidance mentions ‘hot spoon bathing,’ but I tend to recommend a clean flannel or cotton wool pad with warm water – just warm enough to slowly melt the solidified oil in the affected gland. 

If this is looking more like preseptal cellulitis, her age presents a few points for discussion – the first question being, is she a child?

Kevin Wallace: This patient is clearly young, but not a child. I would want advice from my local eye department due to that – and her management is what I would use (the clavulanic acid is an adjuvant so that combination is more effective than just, for example, amoxicillin).

NICE Guidance NG204 says that most 17 year olds are capable of making decisions about their health, so unless there’s a reason for that not to be the case it is appropriate to manage them with their consent. I would always ask if they want me to discuss it with a parent too, which I think is good practice. 

Before that, though, we have the clue of recent viral illness. This could simply be an early presentation of acute viral conjunctivitis. I’d be quite happy if, within the next day or so, the other eye is affected, as that makes it more likely to be that. A swollen eyelid is often just an allergic reaction too – it’s a little unusual to only affect one eye, but it is possible.

A thorough examination of the eyes is clearly important. As well as what the others have said, I would want to evert the eyelids and check for a tarsal reaction or a foreign body. It’s important to have a look without the slit lamp, too – a slit lamp is great for examining the small structures of the eye, but it’s often useful to have a wider gross look too.

As Ankur says, the position, shape, and colour of the lid swelling is very helpful in coming to a conclusion. I’d be more worried if the lid is red or purple, and particularly if the patient was feeling unwell, which would indicate a more serious infection.

Depending on the results of my investigations, I’ve narrowed the treatment down to antibiotics for a bacterial infection, which may be topical or systemic, antihistamines for an allergy, a warm compress, and a cool compress. Also, I would advise her to lubricate to make herself feel better.

If I don’t think it is something significant, I would want to follow up the patient closely over the next few days – any deterioration in symptoms I’d want to know about it, especially if she starts to feel unwell.

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