treatment plan
Investigating Swollen Eyelids
BY LEO SEMES, OD, FAAO

Patients who present with swollen eyelids represent a diagnostic challenge. Measuring body temperature can help you distinguish between unilateral preseptal (lid) cellulitis and the more dangerous orbital cellulitis (fever is more characteristic of the orbital variety). Itching generally accompanies allergic reactions. Insect bites and hordeola or chalazia each have characteristic clinical features.

Once you establish that the diagnosis excludes post-tarsal involvement, you can consider management options. These include a market basket of oral medications. Prompt treatment augmented with cold compresses and topical antibiotics for conjunctival involvement usually provides relief within a few days.

Figure 1. Note the significant edema in the patient's affected right eye.

A Case of Preseptal Cellulitis

Here's an example that illustrates some oral medication considerations. A 78-year-old female reported for an urgent visit because of a swollen right lid. Her symptoms had begun two days earlier and included tenderness to touch and mucus discharge that matted lids together on waking, but didn't decrease vision. Figure 1 shows the clinical appearance.

Preseptal cellulitis often accompanies upper respiratory infections or sinusitis. Common causative organisms are Staphylococcus aureus, Staphylococcus epidermidis and Strep species. You may not identify causative bacteria, as empirical treatment usually suffices. Comprehensive empirical antimicrobial therapy was indicated in this case.

No dogma for treatment of choice exists for this condition, so clinicians have many options. Treatment suggestions from The Wills Eye Manual include Augmentin (amoxicillin and potassium clavulanate in various dosages and forms), Ceclor (250mg or 500mg cefaclor), Bactrim or Septra and their clones (sulfamethoxazole and trimethoprim in various dosage combinations and formulations) or even erythromycin. Alternatives include Zithromax (azithromycin in various dosages) and dicloxacillin. You can find even more suggested treatments on the Internet.

Choosing Among Medications

With so many possible treatments on the menu, selecting the best one still posed a challenge. As part of her history, the patient indicated allergy to sulfa drugs, which eliminated Bactrim. Additionally, she indicated that her co-pay through her insurance for generic drugs was $5.00, but that she had to pay the full amount for nongenerics. Taking that into consideration also eliminated Zithromax.

Ceclor and Augmentin, however, are available in generic form. I decided to prescribe dicloxacillin (500mg qid). My patient returned in three days with improved signs and symptoms, and the preseptal cellulitis completely resolved in seven days.

Lessons Learned

This case provided several treatment lessons. To start, a number of medications exist that we can prescribe for this condition. The patient's allergy to sulfa limited our overall choices, but still left at least five possibilities. Her insurance issue further minimized choices. But, because the patient didn't report allergies to any of the remaining medications, all were viable.

I selected dicloxacillin arbitrarily. The spectrum of activity of dicloxacillin covers all of the likely possible causative bacteria of preseptal cellulitis. However, second and third generation cephalosporins (for example, Zinacef [cefuroxime] and Rocephin [ceftriaxone]) may also have resolved the condition.

Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.