Diagnosing and managing swollen eyelids

The question:

I’m looking for general advice on the management of patients with swollen eyelids. I'm unsure at which point to treat an internal hordeolum with antibiotics, and whether the antibiotics prescribed should be topical or systemic. What should I do if the condition is bordering on preseptal cellulitis?

OT’s panel says...

Ceri Smith-Jaynes (CSJ): There are many conditions that can cause the lid to swell, such as corneal abrasion, ocular rosacea, allergy, contact dermatitis, external or internal hordeolum, or preseptal or orbital cellulitis. You’ll have a good idea of what you are dealing with after a thorough history, but keep the differential diagnoses in mind until you’ve firmed up the diagnosis with the slit lamp. Is the redness and swelling unilateral or bilateral, localised or spread-out? Don’t forget to check the visual acuity, check the cornea with fluorescein, and flip the lids over if you can. How is the patient feeling?

Farah Topia: A red and tender swelling of the eyelid is usually due to a bacterial infection. Internal hordeolum affect the meibomian glands and external hordeolum affect the glands around the eyelashes. Patients will complain of tenderness and redness, and there may be some discharge. A hot compress (five–10 mins several times a day) can help the lesion drain more quickly. In many cases, the condition can resolve spontaneously.

It is important to keep a close watch on things as there is a risk of the internal hordeolum recurring and developing into a chalazion, and of the infection spreading to other tissues and glands around the eye.

Topical antibiotics (chloramphenicol) may be prescribed in the first instance if there is significant discharge. This can be in the form of either drops or ointment. I tend to recommend the ointment as it remains in the eye for longer, but some patients find the blurring effect on the vision annoying.

It is important to keep a close watch on things as there is a risk of the internal hordeolum recurring and developing into a chalazion, and of the infection spreading

Kevin Wallace (KW): I agree that a warm compress is the most important treatment. Usually, I would only give antibiotic ointment if the lump is particularly red and angry. Most acute hordeola will resolve in a week or so and I find the ointment applied to the eyelid quite effective. A chalazion can be frustrating for patients, but they can take months to resolve. Locally, our guidance is that curettage will only be considered after three months of moist heat, because the vast majority will resolve in that time.

CSJ: Patients can find a hordeolum quite distressing, but there’s often no quick fix. If it is external and just around one lash, it may help to epilate the lash. I encourage patience and persistence with the warm compress, gentle massage and lid cleaning (of both eyes, because it’s often due to neglected blepharitis). Blocked/infected meibomian glands are harder to get at and I generally find topical antibiotics aren’t very effective because the infection is deep down in the gland. Really severe cases may require an oral antibiotic such as co-amoxiclav. If it turns into a painless, hard lump it’s a chalazion. If a chalazion is large, recurrent or inducing corneal astigmatism, it needs a routine referral to ophthalmology.

In children, both preseptal cellulitis and orbital cellulitis are sight and life-threatening emergencies, requiring immediate referral. Watch for fever and malaise, a warm, swollen lid that extends beyond just one gland, ptosis, pain, and restriction of eye movement.

In adults, orbital cellulitis is an emergency but if it is preseptal, I would still speak to the on-call ophthalmologist. In my area, they usually suggest I start oral antibiotics and then they will follow it up in their clinic.

In simple cases, always advise the patient on what to expect, what to do if it gets worse, what symptoms to watch out for, and when to come back.

KW: The vast majority of lid infections need simple treatment as we have discussed. With practice, it gets easier to recognise the ones that may need something more intensive. The key is to seek advice when you’re not sure. Particularly in children, it’s important to have a low threshold for suspecting preseptal or orbital cellulitis.

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