Swollen Eyelids, Causes, Symptoms, Diagnosis, Treatment

Swollen Eyelids or Swollen red eyelid is a common presentation in primary care. An understanding of the anatomy of the orbital region can guide care. Factors that guide diagnosis and urgency of care include the acute vs. subacute onset of symptoms, presence or absence of pain, the identifiable mass within the eyelid vs. diffuse lid swelling, and identification of vision change or ophthalmoplegia. Superficial skin processes presenting with swollen red eyelid include vesicles of herpes zoster ophthalmicus; erythematous irritation of contact dermatitis; raised, dry plaques of atopic dermatitis; and skin changes of malignancies, such as basal or squamous cell carcinoma. A well-defined mass at the lid margin is often a hordeolum or style. A mass within the midportion of the lid is commonly a chalazion. Preseptal and orbital cellulitis are important to identify, treat, and differentiate from each other. Orbital cellulitis is more often marked by changes in the ability of extraocular movements and vision as opposed to preseptal cellulitis where these characteristics are classically normal. Less commonly, autoimmune processes of the orbit or ocular tumors with mass effect can create an initial impression of a swollen eyelid.

Why Do Eyes Swell After Crying?

The watery component of tears is produced in the lacrimal glands near the eye and are essential for healthy eyes, keeping the eyes cleansed, protected and lubricated. Tears drain through the nasal cavity, which explains a runny nose after excess tear production.

There are three types of tears

• Basal tears –  which provide a constant film of tears to keep the eye moist.
• Reflex tears – which protect the eyes when they are exposed to irritants such as smoke or come into contact with a foreign body.
• Emotional tears –  which are produced in response to a strong emotion.

With emotional tears, the lacrimal glands are sent into overdrive, producing a continuous flow of watery tears. The fine tissues around your eyes absorb some of the overflows of tears, causing the eyes to become temporarily puffy and swollen.

Anatomy of Swollen Eyelids

The eyelid is a complex, fully functioning skin tissue that consists of eyelashes, lacrimal (tear) glands, sebaceous (oil or meibomian) glands, and sweat glands (glands of Zeis or Moll).[rx]

These structures can develop inflammatory reactions leading to a red, swollen eyelid. The lacrimal glands produce tears that run medially over the cornea and drain into the nasolacrimal sac.[rx] The eyelid and conjunctivae are colonized by the usual flora of the body, including fungi and S. aureus.[rx,rx]

The orbits contain the globe, muscles for eye movement, optic nerve, arteries, veins, and surrounding fat. The orbital septum creates an anatomic barrier of connective tissue that runs from the periosteum of the skull through the eyelid. The orbital septum separates preseptal tissues from the orbital tissues. Anatomically, the eyelid is part of the septal tissue. Tumor effect and inflammation posterior to the orbital septum can disrupt blood flow to the globe, impede the function of the optic nerve, affect vision, and limit the function of ocular muscles.[rx,rx]

The paranasal sinuses (maxillary, frontal, ethmoid, and sphenoid) abut the orbit on three sides.[rx] The lateral aspect of the ethmoid bone is called the lamina papyracea (Latin for “layer of paper”). It forms a thin, bony separation that can allow extravasation of inflammation from the ethmoid sinus into the orbital cavity.[rx,rx,rx]

Venous flow from the orbital region drains into the ophthalmic veins and subsequently the cavernous sinus. The teeth are in close proximity to the area, and dental pathology can present with orbital symptoms.[rx,rx]

The eyelid can appear swollen because of processes in the eyelid or mass effects from the tissues posterior to the orbital septum. Prompt diagnosis is vital to guide appropriate therapy and avoid vision loss. Issues that warrant immediate ophthalmology consultation include penetrating trauma through the eyelid or into the globe, a change in vision such as diplopia, and loss of extraocular movements (ophthalmoplegia).[rx,rx,rx]

Causes of Swollen Eyelids

Nearly everyone experiences swollen eyelids at some point in their lives, typically from irritation, infection, or allergies. However, there are other common conditions that may be more serious, which require an eye exam for an appropriate diagnosis rather than home treatment.

• Contact allergy – Getting a particle of dust, pollen, or pet dander in your eye can cause a small amount of irritation, which may lead to swelling. If you do not have an overall allergic reaction, swelling and itching will go away on their own. You may benefit from taking an antihistamine to control the inflammation. If the swelling does not go away on its own after one or two days, see a doctor. Some of the tissues in or around your eye may have an infection.
• Widespread allergy – If you struggle with allergies to plants, animals, or dust, you may frequently develop puffy, swollen, red, watery, itchy, or dry eyes. Antihistamines or anti-inflammatory medications can reduce some of these symptoms. If you have severe allergies, working with a doctor to manage prescription medications will reduce eye swelling since it is a symptom of your allergies.
• Eye irritation – Getting a particle of makeup or dirt in your eye can temporarily irritate your orbital socket and cause a small amount of puffiness or swelling. Remove contact lenses if you are wearing them, and gently wash your eye out with water or eye drops. Do not put contact lenses back in until swelling has gone away.
• Blepharitis – This may be an infection of the tissues around the eye, or it could be associated with the herpes simplex virus. Along with eyelid swelling, you may notice yellow crust along the eyelashes, itching or burning eyes, redness, and sores. This typically affects both eyes at the same time. A doctor’s examination can determine if blepharitis is causing your symptoms and begin your treatment.
• Chalazion – This is the enlargement of an oil gland inside your eyelid, and it typically affects only one eye at a time. You will develop an enlarged, red, sore area that will look like a small mound. The pain will go away first, followed by decreased swelling. A doctor’s examination is required for treatment because it will not go away on its own.
• Conjunctivitis – More commonly known as pink eye, this is an infection characterized by redness, discharge, and sometimes crust on the eyelashes. It can affect one or both eyes, and it may look like an allergic reaction at first. Symptoms will get worse, not better, so see a doctor for medicated eye drops and stop wearing your contact lenses immediately.
• Stye – The medical term for a style is hordeolum, and this typically is a red, inflamed, painful area in one eyelid. Eventually, the swelling will even out, sometimes with small, raised, pus-filled bumps. Visit a doctor for treatment recommendations if it doesn’t clear in a couple days.
• Insect bite – Itching, redness, and a small bump suggest you may have been bitten by an insect, but a doctor will be able to accurately distinguish between an insect bite and other potential causes of eyelid swelling
• Shingles – This is the same virus that causes chickenpox, which lies dormant after the initial infection but may become active again in adulthood. The most common symptoms are skin rash and pain, particularly along the sides or flanks of the body. In rare cases, you may develop a rash around the face, which can cause swelling in or around your eyelids.
• Orbital cellulitis – Tissue infection in or around the eye socket can present as eyelid swelling. This will be accompanied by redness, pain in the eyeball, and bulging eyes. It will start in one eye and spread to the other.
• Preseptal/periorbital cellulitis – Like orbital cellulitis, this is an infection of skin tissue, but it occurs around the outside of the eye rather than the interior tissues. This may be accompanied by pain and fever.
• Hypothyroidism – An underactive thyroid gland mostly causes fatigue and weight changes, but puffy or swollen eyes may be one of several symptoms that your body is not managing hormone production. This requires a doctor’s diagnosis to begin treatment.
• Graves’ disease – The opposite of hypothyroidism, this condition involves an overactive thyroid gland caused by an immune problem. Bulging eyes, double vision, anxiety, weight loss, and rapid heartbeat are all symptoms of Graves’ disease, which can only be diagnosed by a medical professional.
• Systemic disorders (preeclampsia, kidney disease, cardiovascular disease, and liver failure) – Edema, or fluid retention, is a symptom of many diseases that affect the whole body. The eyes are one of several areas where you may notice unusual swelling.

Symptoms of Swollen Eyelids

Barley infection on the eye.

• Itching or scratchy sensations in or around your eyes.
• Sensitivity to light.
• A burning or gritty feeling in your eye
• Blurred vision
• Crusted eyes when you first wake in the morning
• Obstructed vision (depending on the extent of the swelling)
• Redness of the eyelid
• Red eyes and inflammation of the conjunctiva
• Eye discharge
• Eyelid dryness or flaking
• Pain, particularly when swollen eyelids are caused by infection
• Dry eyes
• Eyelashes that grow at different angles
• Greasy eyelids
• Itchy eyes
• Red eyelids
• Swelling
• Watery eyes.
• Redness in the whites of the eyes.
• Obstructed vision.
• Dryness or flaking skin on or around the eyelid.
• Pain or feeling hot (symptoms of infection).

Diagnosis of Swollen Eyelids

Swollen Eyelids can be diagnosed through a comprehensive eye examination. Testing, with special emphasis on the eyelids and the front surface of the eyeball, may include:

• Patient history to determine – any symptoms the patient is experiencing and any general health problems that may be contributing to the eye problem.
• External examination of the eye – including lid structure, skin texture, and eyelash appearance.
• Evaluation of the lid margins – the base of the eyelashes and meibomian gland openings using bright light and magnification. Evaluation of the quantity and quality of tears to check for any abnormalities.
• Staphylococcal swollen eyelids, – patients frequently exhibit mildly sticking eyelids, thickened lid margins, and missing and misdirected eyelashes.
• Seborrheic swollen eyelids,  – patients have greasy flakes or scales around the base of eyelashes and a mild redness of the eyelids.
• Ulcerative swollen eyelids, – patients have matted, hard crusts around the eyelashes. Removing the crusts leaves small sores that ooze and bleed. These patients may also experience eyelash loss, distortion of the front edges of the eyelids and chronic tearing. In severe cases, the cornea (the transparent front covering of the eyeball) becomes inflamed.
• Meibomian blepharitis – patients have a blockage of the oil glands in the eyelids, poor quality of tears and redness of the lining of the eyelids.

Treatment of Swollen Eyelids

Immediate Treatment

Various medications are available for the treatment of allergy symptoms:

• Antihistamines
• Steroids (corticosteroids)
• Chromones (mast cell stabilizers)
• Leukotriene receptor antagonists
• Decongestant nasal drops and sprays

There are also non-drug alternatives such as saline (salt water) nasal sprays and nasal washes (nasal irrigation).

Basic  Treatment

• Eye lid hygiene – Initial treatment is eyelid hygiene, it has three components, warm compresses, eyelid massage, and eyelid scrub. Warm compresses should be done for at least 5 minutes, followed by lid massage at least once daily. The warm compresses help to melt the altered secretions of the meibomian glands. Eyelidmassage, this is compressing the eyelid against the eyeballs, it helps to milk excess secretions from the meibomian glands. By eyelid scrub, eyelid margin is washed mechanically and clean the gland orifices which consist of gently scrubbing the eyelids with a wet washcloth. This is performed after the warm compresses.
• Artificial tears – The tear film in patients with blepharitis is abnormal, and artificial tears may provide considerable relief of symptoms
• Topical antibiotics – Topical antibiotics are used to treat both Staphylococcal and seborrheic blepharitis, preferably in an ointment form, They are applied usually at bedtime. It is smeared on the lid margin to reduce the staphylococci flora in the lid. This treatment is required for several months to have a reasonable response. The ointment is applied after lid hygiene is done. Treatment regimen would be once or twice daily depending on the severity of the inflammation. Commonly used antibiotics are fusidic acid gel, erythromycin and bacitracin. Antibiotic therapy may be discontinued in two to eight weeks or once symptoms resolve. But in some patients with severe disease. treatment will require for a long duration to keep the patient symptom free.
• Several topical treatments – Yellow mercuric oxide ophthalmic ointment (older publications), parasympathomimetic agents (physostigmine, pilocarpine), 20% fluorescein, and liquid petrolatum ointment have been reported to be efficient on lice and nits. Topical antiparasitic agents such as natural pyrethrins, pyrethroids, malathion, and lindane (sometimes erroneously reported as gamma-benzene hexachloride) may also be prescribed.
• Topical antiseptics – Bibrocathol is an antiseptic drug for the treatment of acute eyelid diseases. Eye ointments containing 2 or 5 % bibrocathol are used to treat the eyelid.
• Topical steroids – Topical steroids may improve anterior blepharitis but frequent use is best avoided[4] All forms of blepharitis may benefit from a course of treatment with topical corticosteroid drops to decrease inflammation in an acute exacerbation. Should applying drops several times daily, tapered to discontinuation over one to three weeks as it has significant adverse effects over the long-term such as increased intraocular pressure (IOP), posterior subcapsular cataract formation, and superinfection. For this reason, they are not recommended for long-term use
• Oral antibiotics – In patients with posterior blepharitis oral tetracycline or doxycycline may is effective
• Medications that affect the immune system – Topical cyclosporine (Restasis) is a calcineurin inhibitor that has been shown to offer relief of some signs and symptoms of blepharitis.
• Treatments for underlying conditions – Blepharitis caused by seborrheic dermatitis, rosacea or other diseases may be controlled by treating the underlying disease.
• Steroid eyedrops/ointments – Eye drops or ointments containing corticosteroids are frequently used in conjunction with antibiotics and can reduce eyelid inflammation.^[rx][rx][rx]
•  Hypochlorous acid products – Both over-the-counter and prescription products with hypochlorous acid (HOCl) can be used to alleviate the signs and symptoms of blepharitis. In a recent study, a saline hygiene solution with hypochlorous acid was shown to reduce the bacterial load significantly without altering the diversity of bacterial species on the eyelids. After 20 minutes of treatment, there was >99% reduction of the Staphylococci bacteria, which is a common cause of blepharitis.^[rx]
• Cryotherapy  – with liquid nitrogen performed under the slit lamp was reported to be efficient by some authors. Some authors have proposed argon laser therapy as an effective treatment for phthiriasis palpebrarum. One session using a 200-micron beam, with a duration of 0.1 seconds, and a power of 0.2 W allowed the destruction of both lice and nits. However, this device necessitates strict eye protection and may not be available on a large scale.
• Oral ivermectin –  may be used as a single dose treatment; however, a second dose may be necessary after seven to 10 days to control newly hatched nits. Oral ivermectin is contraindicated in children younger than five years old and/or weighing less than 15 kilograms, as well as in pregnant and lactating women. Treatment of associated body hair infestation, using antiparasitic topical and/or shaving is mandatory.
• Clothing, bedding including pillowcases – and towels should be washed at 50 C for half an hour and then heat dried for up to 10 minutes to eliminate both lice and nits. All sexual contacts and family members of a person having phthiriasis palpebrarum should be evaluated for the presence of phthiriasis pubis and phthiriasis palpebrarum, and if necessary, they have to be treated. The effect of such measures in preventing recontamination has been proven.
• Warm compress – Using a warm compress simply means placing a warm cloth over closed eyelids, reheating the compress with warm water when it cools and reapplying for up to 10 minutes. Dipping the cloth in warm water: Some patients have suffered facial burns by using a microwave to heat up the wet cloth. Using a soft cloth only: Scrubbing too vigorously or using a rough cloth can damage the skin and eyes. After applying a warm compress for up to 10 minutes, cleanse the eyelids.
• Warming eye masks –These may achieve the same effects as the warm cloth compresses, and they may be more convenient. Eyelid cleansers are also available and offer an alternative to the use of dilute baby shampoo.
• Cleanse the eyelids – To do this, gently rub the margin of the eyelid—at the base of the eyelashes, and where the glands are located—with a cotton swab soaked in a dilute solution of baby shampoo. Use 2 to 3 drops in about half a cup of warm water. This lid hygiene needs to be maintained as a self-care regime twice a day every day. This is a considerable lifelong commitment, but the symptoms will come back without it.
• How to massage the eyes – After using the warm compress to loosen the sebum, massaging helps express the oily contents of the glands. With a finger or a cotton-tipped applicator or swab, massage the margin of the eyelid, where the eyelashes and glands are, using small circular motions.
• Diet – There’s some evidence to suggest a diet high in omega-3 fats can help improve blepharitis.

The best sources of omega-3s are oily fish, such as:

• Mackerel
• Salmon
• Sardines
• Herring
• Fresh or frozen tuna – not canned, as the canning process sometimes removes the beneficial oils

Aim to eat at least two portions of fish a week, one of which should be oily fish. You can also get omega-3s from various nuts and seeds, vegetable oils, soya and soya products, and green leafy vegetables. Omega 7 or sea buckthorn oil has also been found to be helpful.

Tips For Preventing Swollen Eyes

• Get tested for allergies – If swollen eyelids and other symptoms of allergies are a regular occurrence, get yourself allergy tested. By knowing what you’re allergic to, you can try to avoid specific allergens or, at the very least, minimize your exposure to them.
• Choose makeup and other beauty products that are hypoallergenic and fragrance-free – to help avoid allergic flare-ups. You can also do a patch test on the inside of your wrist before using the makeup on your face to rule out any allergic reaction.
• When using eye drops – look for preservative-free eye drops. While preservatives in regular eye drops inhibit bacterial growth, some people are allergic to these preservatives.
• If you wear contact lenses – you can minimize your risk of eye infection or irritation by practicing proper hygiene techniques, including frequent replacement of your contact lenses and contact lens case.

Complications

If you have blepharitis, you may also experience

• Eyelash problems – Swollen Eyelids can cause your eyelashes to fall out or grow abnormally (misdirected eyelashes).
• Eyelid skin problems – Scarring may occur on your eyelids in response to long-term swollen eyelids. Or the eyelid edges may turn inward or outward.
• Excess tearing or dry eyes – Abnormal oily secretions and other debris shed from the eyelids, such as flaking associated with dandruff, can accumulate in your tear film — the water, oil and mucus solution that forms tears. Abnormal tear film interferes with the healthy lubrication of your eyelids. This can irritate your eyes and cause symptoms of dry eyes or excess tearing.
• Difficulty wearing contact lenses – Because swollen eyelids can affect the amount of lubrication in your eyes, wearing contact lenses may be uncomfortable.
• Sty – A sty is an infection that develops near the base of the eyelashes. The result is a painful lump on the edge (usually on the outside part) of your eyelid. A sty is usually most visible on the surface of the eyelid.
• Chalazion – A chalazion occurs when there’s a blockage in one of the small oil glands at the margin of the eyelid, just behind the eyelashes. The gland can become infected with bacteria, which causes a red, swollen eyelid. Unlike a sty, a chalazion tends to be most prominent on the inside of the eyelid.
• Chronic pink  – Swollen Eyelids can lead to recurrent bouts of pink eye (conjunctivitis).
• Injury to the cornea – Constant irritation from inflamed eyelids or misdirected eyelashes may cause a sore (ulcer) to develop on your cornea. Insufficient tearing could predispose you to a corneal infection.

References

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