treatment plan

Managing a Case of Swollen Eyelids

BY LEO SEMES, OD, FAAO

An 11-year-old girl presented with a one-day complaint of unilateral red, swollen upper and lower left lids. She experienced no subjective decrement of vision and no pain on blinking. There was no apparent history of trauma or other insult. Present were mild itching and a mildly red eye. The patient reported no period of upper respiratory infection or fever.

Corrected visual acuity was 20/20 in each eye. There were no pupillary or EOM deficits. During the physical examination, we found erythema and edema of the upper and lower left lids and a 2+ follicular response in the inferior palpebral conjunctiva, but normal cornea, anterior chamber, and iris. No proptosis was evident. We diagnosed preseptal cellulitis.

Treating This Case

We asked the patient about sensitivity reactions to antibiotics and prescribed Augmentin 375 (250 mg amoxicillin and 125 mg clavulanic acid, GlaxoSmithKline) b.i.d. for 10 days. It is rare to culture for causative bacteria as empirical treatment usually suffices, therefore empirical antimicrobial therapy was indicated in this case.

Preseptal (or lid) cellulitis often accompanies upper respiratory infections or sinusitis. Common causative organisms are S. aureus, S. epidermidis, and Strep species. We ran no culture and sensitivity on this patient, and the case resolved almost completely within three days of initiating treatment. There was complete resolution by the fifth treatment day, and we kept the patient on the antibiotic regimen for the full 10 days as initially prescribed.

Other Treatment Options

A number of medications are available for treating preseptal cellulitis. The selection of Augmentin was based on the suspected causative agent falling within the drug spectrum of action. Second- and third-generation cephalosporins (for example, cefuroxime [Zinacef, GlaxoSmithKline] and ceftriaxone [Rocephin, Roche Laboratories]) may be effective, too. Ceclor (250mg or 500mg cefaclor, Eli Lilly and Co.), Bactrim (AR Scientific, Inc.), or Septra (Monarch Pharmaceuticals) and their clones (sulfamethoxazole and trimethoprim in various dosage combinations and formulations), or even erythromycin would also work. Alternatives include Zithromax (azithromycin in various dosages, Pfizer Pharmaceuticals) and dicloxacillin. The choices are wide and may be limited by such factors as sensitivity to a particular antibiotic, what may be available generically, or limited further by a patient's pharmacy panel.

Lid Versus Orbital Cellulitis

Patients who present with swollen lids represent a challenge diagnostically. To distinguish between unilateral preseptal (lid) and the more dangerous orbital cellulitis, measuring body temperature is helpful. Fever is more characteristic of the orbital variety. This may be a life-threatening condition, so prompt hospitalization is required and should be continued until the patient's fever returns to normal and clinical improvement is evident.

Intravenous broad-spectrum antibiotics should be started immediately until the choice of antibiotics can be tailored for specific pathogens identified on cultures. Typically, intravenous antibiotic therapy should be continued for one-to-two weeks and then followed by oral antibiotics for an additional two-to-three weeks. Fungal infection requires intravenous antifungal therapy along with surgical debridement.

Other differential diagnoses include allergic reactions, which are generally accompanied by itch and may have an identifiable allergen associated. Insect bites and hordeola or chalazia have characteristic clinical features. CLS

Dr. Semes is a professor and director of continuing education at the University of Alabama at Birmingham School of Optometry.