Minor Care Series: The Swollen Eyelid

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Background

Eyelid and eye swelling is a common complaint in any ED setting.  This complaint can have numerous etiologies (infectious, allergic, inflammatory).  In this post we will cover a few of the most common causes of the swollen/red eyelid: hordeolum, chalazion, dacryoadenitis, and dacryocystitis.

Hordeolum and Chalazion

Figure 1. Hordeolum.  COurtesy of Wikimedia Commons (9).

Hordeola and chalazia are two common causes of the red, swollen eyelid encountered in the Emergency Department.  They can be readily distinguished with a careful history and physical exam.  

  • Hordeolum: painful, acutely inflamed eyelid gland.  Often colloquially called a stye.
  • Chalazion: non-painful, sterile, granulomatous, chronic inflammation of an eyelid gland.

The glands most affected are the glands of Zeiss (provide lubrication to the shaft of the eyelash hair follicle) and the Meibomian glands (provide lubrication to the inner eyelid).  If untreated, a hordeolum will typically spontaneously resolve.  However, in refractory cases, it may become significantly purulent leading to surrounding cellulitis.  In other cases, it can become chronically inflamed and turn into a chalazion.  

Figure 2. Chalazion.  Courtesy of wikimedia commons (10).

The general initial treatment is the same for both hordeola and chalazia.  This includes warm soaks 3-4 times daily for 10-15 minutes.  Topical antibiotics have not been shown to hasten resolution.  However, in severe or recurrent cases of pyogenic hordeola, there is some literature to suggest that a course of oral antibiotics may be beneficial (such as erythromycin or dicloxicillin).  Establishing follow-up with ophthalmology is recommended if these lesions do not improve with conservative therapy, as they may need evaluation for possible incision and drainage or steroid injections. 

Dacryoadenitis and Dacryocystitis

Figure 3.  Lacrimal Anatomy.  Courtesy of Wikimedia commons (11).

In order to distinguish these two pathologies, it is first important to understand the anatomy of the lacrimal system.  Tears are produced by the lacrimal gland located in the superotemporal region of the orbit.  These tears protect and hydrate the eye and eventually are drained at the superior and inferior lacrimal puncta.  The tears then travel from the canaliculi to the lacrimal sac and then into the nasolacrimal duct to finally discharge into the inferior nasal meatus.  

Dacryoadenitis involves inflammation of the lacrimal gland itself, which can present as either an acute or a slowly progressive chronic process.  In the acute presentation, patients will note a rapid onset of unilateral pain, redness, and swelling in the superotemporal region of the orbit.  The more common manifestation of dacryoadenitis, however, is the chronic form in which patients will display unilateral or bilateral painless enlargement that can last more than a month.  The etiology of acute lacrimal gland inflammation is primarily due to viral infection (mumps, EBV), which is self-limited.  Supportive treatment includes warm compresses and NSAIDs for pain.  If suspicion for bacterial etiology (gonorrhea, staphylococcus) due to significant purulent discharge, health care providers should culture the drainage and start the patient on a first generation cephalosporin.  In patients with chronic lacrimal gland inflammation, effort should be directed toward investigating and treating a possible underlying systemic inflammatory/autoimmune disorder.  In general, patients with either acute or chronic dacryoadenitis should follow up with an ophthalmologist in 2-4 weeks to ensure that their symptoms are improving.

Figure 4.  Dacryocystitis.  Courtesy of eyerounds.org and Dr. Andrew Doan (12).

Dacryocystitis involves inflammation of the lacrimal sac and/or nasolacrimal duct.  Patients experience pain, redness, and swelling over the medial canthal and inferomedial region of the orbit.  This inflammation often originates from sinusitis, especially in patients with abnormal nasolacrimal anatomy (enlarged nasal turbinates, nasolacrimal duct stenosis, deviated septum etc.).  The relative obstruction causes stagnation of tears within the drainage system that becomes infected.  This can lead to a lacrimal sac abscess and surrounding cellulitis.  In addition to the inferomedial location of tenderness, erythema, and edema, physical exam may show purulent drainage from the puncta.  If left untreated, the lacrimal sac can fistulize to the skin or even rupture.  Unlike dacryoadenitis, these infectious tend to be bacterial and therefore antibiotics are almost always indicated.  If there is associated cellulitis, patients may benefit from admission and observation with IV antibiotics, warm compresses, and NSAIDs for pain relief.  An appropriate outpatient antibiotic choice is clindamycin for 7-10 days.  Patients should also be instructed to massage the lacrimal sac in a downward direction to assist with drainage (Crigler massage).  Ophthalmology consults are recommended as definitive treatment is usually surgical (dacryocystorhinostomy), however, instrumentation is often deferred until the infection has subsided.  

Learning Points

  • Hordeola are red and painful while chalazia are typically painless.  Both are conservatively managed with warm compresses.
  • Dacryoadenitis is inflammation of the lacrimal gland.  Acute presentations are typically viral while chronic presentations are often due to an underlying systemic condition. 
  • Dacryocystitis is inflammation of the lacrimal sac and is typically due to an obstruction of the nasolacrimal duct.  These are often bacterial and should be treated with antibiotics.

Authored by Jimmy Summers, MD

Posted by Tim Murphy, MD

References

  1. Alsuhaibani, Adel et al. “Dacrocystitis.” EyeWiki. May 2017. <http://eyewiki.aao.org/Dacryocystitis>.
  2. Carlisle, Robert and Digiovanni, John. “Differential Diagnosis of the Swollen Red Eyelid.” AM Fam Physician. 2015. Jul 15; 92(2): 106-112.
  3. Deschenes, Jean. “Chalazion.” Medscape. April 2017. <https://emedicine.medscape.com/article/1212709-overview>.
  4. Garrity, James et al. “Dacrocystitis.” Merck Manual. January 2018. <https://www.merckmanuals.com/professional/eye-disorders/eyelid-and-lacrimal-disorders/dacryocystitis>.
  5. Garrity, James et al. “Chalazion and Hordeolum.” Merck Manual. January 2018. <https://www.merckmanuals.com/professional/eye-disorders/eyelid-and-lacrimal-disorders/chalazion-and-hordeolum-stye>.
  6. Kanski JJ. Acute dacryoadenitis. In: Clinical Ophthalmology. A Systematic Approach. 6th ed. Butterworth, Heineman, Elsevier; 2008:178-179
  7. Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, Hernandez JL Dacryocystitis: Systematic Approach to Diagnosis and Therapy .Curr Infect Dis Rep. 2012.
  8. Singh, Gagan. “Dacroadenitis.” Medscape.  March 2015. <https://emedicine.medscape.com/article/1210342-overview>.
  9. https://commons.wikimedia.org/wiki/File:Stye02.jpg
  10. https://commons.wikimedia.org/wiki/File:Chalazion2_01242005_(cropped).jpg
  11. https://commons.wikimedia.org/wiki/File:Tear_system.svg
  12. http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/dacryocystitis-2.html