Swollen Eyelids: Causes, Treatments, and When to Worry

There are many causes of swollen eyelids in kids (and adults). The good news is that the most common ones are usually not serious. Some swellings herald warning though and should be properly evaluated and treated by a doctor. Warning signs include vision changes, pain, protrusion of the eye, fever, difficulty breathing, abnormal eye movements (or loss of movement), foreign body that cannot be removed, or signs of anaphylaxis (swollen tongue or throat, difficulty breathing, hives). Any warning signs deserve prompt medical attention.

Allergies can make the eyelids puffy due to the histamine reaction. This is usually accompanied by itching, red eyes that are watery. Treatment involves either oral allergy medicines, topical allergy medicine (eye drops) or a combination of both. Washing the face, hair, and eyes after exposure to allergen can also be an important part of treatment.

Anaphylaxis is a more serious allergic reaction. It involves swelling of the eyelids, throat, and airways. This is a medical emergency. If epinephrine is available, use it. Call 911.

Blepharitis is an inflammation of the eyelids that can cause swollen lids, often with flaky eyelid skin and loss of the lashes. This chronic condition should be managed by an eye care specialist.

Bug bites are the most common cause of swollen eyelids we see in our office. Usually there is a known exposure to insects and there may be other bug bites on the body. Bug bites on the eyelid tend to itch rather than hurt despite the significant swelling they produce. There should be no fever or other signs of illness. The eyeball should move freely in the socket. (See "orbital cellulitis" below.) Treatment of bug bites involves cool compresses and oral antihistamines. Occasionally oral steroids are required for significant swelling, but they require a prescription. If the swelling is concerning to you or your child, bring him in to be seen.

Conjunctivitis, also known as pink eye, causes inflammation of the surface of the eye ball and sometimes a puffy appearance to the eye lids. It can be from bacteria, virus, or allergies. Bacterial conjunctivitis causes the whites of the eyes to look red and includes a yellow discharge from the eye. Viral conjunctivitis causes the white of the eye to look red, but there is no yellow discharge. Allergic conjunctivitis is described above under "allergies." If unsure which type your child has, or if it is probably bacterial, see your doctor.

Contact lenses can contribute to swollen eyes if they are dirty or damaged. See your eye doctor in this case.

Crying can cause the eye lids to become puffy. The lacrimal glands produce an overflow of tears, so the fine tissues around the eyes absorb the fluid, causing them to appear swollen. This is compounded by the autonomic nervous system increasing blood flow to the face during times of strong emotion and rubbing the eyes to wipe away the tears. This cause of swelling is short lived. Cool compresses and avoidance of rubbing can help decrease the swelling.

Graves' disease can cause swelling of the eyelids and protruding eyes. Sometimes a drooping eyelid or double vision occurs. It is caused by thyroid problems, which also can cause problems with appetite, fatigue, heat intolerance, and more. These symptoms should be evaluated by a doctor.

Kidney problems can lead to fluid retention. If the eyes are puffy along with puffiness of the ankles or swelling of the abdomen, kidney problems should be considered. Children can develop this suddenly from infections, like certain diarrheal illnesses or Strep throat. The urine may look tea colored or like it has blood in it. This is a medical emergency and you should seek care immediately.

Sinus infections can cause puffy eyelids. Congestion, runny nose, headache, postnasal drip, and cough are typical symptoms. See your doctor if you suspect sinusitis.

Styes look like a swelling at the edge of the eyelid, often red or pink with a small white central area. It is caused by a blockage in one of the small glands in the eyelid. Another swelling from blockage of oil glands of the eyelid is a chalazion. Both a stye and a chalazion can start as painful bumps, but after a few days they no longer hurt. They can cause the whole eyelid to swell. Applying warm packs to the area several times per day often helps treat styes. Chalazions more often need to see an ophthalmologist for treatment. If a stye persists beyond a few months or the lid swells to cover the pupil, see your doctor.

Trauma of the eye or nose, like any trauma, can cause swelling. A broken nose can cause swelling and bruising to the eyelids. Any significant trauma to the eye or nose should be seen by a doctor. Symptoms may include vision changes, chemical exposure, foreign body in the eye, blood in the eye, severe pain, or nausea or vomiting after injury.

Ocular herpes is an infection of the eye by the herpes virus. (Not all herpes infections are sexually transmitted!) It can appear initially like a blister or cluster of blisters near the eye. It can lead to permanent damage to the eye, so prompt care by an ophthalmologist is important.

Orbital cellulitis is a potentially serious infection of the eyelids. The infection can extend behind the eyes, causing meningitis. It is suspected when there is painful swelling of the upper and lower eyelids, fever, bulging eyes, vision problems, and pain with eye movement (or inability to move the eyes). This is a medical emergency and if suspected, prompt medical attention is warranted. Treatment involves iv antibiotics. To assess the extent of swelling or to differentiate between pre-septal cellulitis (which is not into the deep tissues) and orbital cellulitis, imaging is often done.

Ptosis, or drooping of the eyelid, can look like a swollen lid. There are many causes and this should be evaluated by a doctor.

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Eye Exams for All Children!

I often find that when I tell parents to start taking their children to the eye care specialist, the advice is not followed. Even at the 3 year well visit when I suggest a free screening, so I know it isn't always about the cost. We are all busy. I get that. But our eyes are important, and many pediatric eye conditions have much better outcomes if addressed early.

I was excited to see an article, No Child Too Young for Eye Exam in Pediatric News, thinking posting it would help parents. But after reading it, it was a bit technical, and written for physicians. So I thought  I'd break it down and explain why eye checks by an eye care specialist is so much more than a vision screen at school or the doctor's office. (I have stopped recommending vision screenings in my office - though they are still offered- because if insurance limits to only one screen per year, I want it done by someone who looks at the entire eye. See the second scenario in Middle Man Payment Plan for more.)

First, what do I mean by seeing an eye care specialist? Eye care specialists include Ophthalmologists and Optometrists. Ophthalmologists are physicians who went to medical school to obtain an MD (Medical Degree) or DO (Doctor of Osteopathy) degree and then did their residency in opthalmology. They can do eye exams as well as treat problems medically or surgically.  Optometrists go to school specifically to diagnose and treat eye conditions. Their degree is OD (Optometry Degree). They focus on routine eye care and vision correction. Both of these specialists can have specific areas of expertise and may or may not treat kids, so always be sure they have experience with kids the ages of your children.

In the article referenced above, Dr Sherry Boschert discusses myths of eye problems in children. These myths:

1. My child is too young for an eye exam. Not true. Ophthalmologists are routinely consulted in the Newborn ICU to see newborns for various eye concerns. Thankfully they don't have to be able to tell if view #1 or #2 looks better... even at my age, this is very difficult! Eye doctors can be specially trained to evaluate a newborn's eyes adequately.

2. Tearing must be due to a blocked tear duct. Many infants have blocked tear ducts, which causes the eye to water often. Since it is so common, it is most likely that your child with a tearing eye has a blocked tear duct. But... if it comes with pain or light sensitivity there might be more going on like a scratch on the eyeball or increased pressure within the eye.

What is a blocked tear duct? Just as it sounds, the tube that drains tears from the eyes into your nose become blocked. Tears are made in glands in the eyelid, cross the eye to moisturize it, then drain into the nose. With the drainage tube blocked, tears well up in the eye and it looks like the eye is crying. Usually this self-resolves by about 9 months of age, and parents can help by massing the area of the tube several times/day. It can lead to matting and drainage from the eye, but without redness or pain does not require any other treatment the first 9 months of life.  If it persists longer or if it leads to a discolored swelling below the eye we refer to an ophthalmologist (eye surgeon) for treatment.

Corneal abrasion is the medical term for scratch on the eyeball. How does this happen? Babies keep their hands near their face often and can get a fingernail in the eye accidentally. Often parents do not know what happened, but baby suddenly cries uncontrollably and won't open the eye. Older kids might be able to tell you that something went in their eye or they simply complain their eye hurts. They might have one area of redness (as opposed to pink eye where the entire eyeball is red). These scratches can be seen in our office with the help of special dye and a black light (Kids think this is pretty cool!) and are treated with antibiotic eye drops and close follow up. Severe trauma should be seen by an ophthalmologist. 

Glaucoma is not common in babies and children, but it is something that needs to be treated emergently by a pediatric eye surgeon (ophthalmologist). These babies appear to have beautiful big eyes, but they are caused by increased pressure within the eye. This pressure must be released to avoid permanent vision damage and treat the associated pain.  

3. All red eyes are contagious. Red eyes can be from viruses and bacteria (the reason schools/daycares kick kids out at the first sign of a red and/or goopey eye), but they can really be from many causes:

• viral conjunctivitis = pink eye from a virus. This is typically red and watery, but no mucus discharge. It usually comes with other typical "cold" symptoms. It is contagious, but like all viruses, no antibiotics help. 
• bacterial conjunctivitis = pink eye from a bacteria. These eyes are red with yellow discharge. Antibiotic eye drops do help contain this from spreading as well as treat the infection.
• allergic conjunctivitis = pink eye from allergies - typically itchy and watery, sometimes red eyes and sometimes a very thin mucus discharge occurs. A careful look at the inner eyelids will show small bumps. These can be treated with typical oral allergy medications or eye drops for allergies (available OTC). Eye doctors will use steroid eye drops for very bad cases, but these should be used with the direction of eye specialists who can check eye pressures to follow potential side effects.
• other illnesses - I commonly see reddened eyes with "sick" kids (Strep throat, upper respiratory infections, etc) who don't meet criteria for a true conjunctivitis.
• irritants - shampoo, smoke, chlorine, or other things entering the eye can irritate it and cause it to temporarily look red. Many of these require a flush of the eye. If pain or redness persists, they eye should be completely evaluated to be sure there is no damage to the eye surface.
• foreign bodies in the eye - sand, eyelashes, and other objects can irritate the eye. If unable to remove them safely at home, the primary care provider can help. If pain persists after removal or if they eye remains red more than 6-8 hours after removal, the PCP should evaluate for infection or abrasion.
• stye - These are bumps in the eyelid, near the eyelashes. If they are deeper within the lid they are called chalazions. They don't usually cause the eye to look red (except the bump itself) but I include it here because I see many kids for "pink eye" diagnosed at daycare, that have no pink eye, just a stye. These can be helped with a warm compresses. I do not feel these need antibiotics or eye drops but the author mentions those as a treatment option. If they grow large enough to cover the pupil or if they last longer than 3 months, an ophthalmologist might need to remove them.
• tired kids often have red eyes, usually parents notice this pattern
• injury - see corneal abrasion above
• sunburn - yes, the eyes can suffer sun damage just like your skin. Wearing sunglasses with UVA and UVB protection and wide-rimmed hats can help prevent this (as well as cataracts, macular degeneration, and other issues). If blistering or severe pain, these should be evaluated by an optometrist or ophthalmologist.
• hemorrhage = bleeding within the eye. This can be common after birth or with coughing or vomiting due to sudden increased pressure within the eye. They self resolve. 
• episcleritis = inflammation of part of the eye covering. The white of the eye can look pink or purple, the eye hurts and is sensitive to light, and it may tear. It typically self-resolves, but an eye specialist can help with the diagnosis.
• pinguecula and pterygium = small growths on the surface of the eye from various causes. An eye specialist can help with diagnosis and management, though typically no treatment is needed.

4. Children outgrow crossed eyes. Many children appear to have crossed eyes due to a wide nasal bridge, and they do "outgrow" this as their face shape matures. This is called pseudostrabismus and is not a problem with the eye.  It can be demonstrated in the photo at the top of this page. The right eye appears to cross in, but if you note the light reflex on the pupils, it is in the same location on both eyes. Truly crossed eyes would show the light reflex on different parts of the eye. This is caused from vision problems, eye muscle problems, or even in rare cases brain masses, and none of those go away without proper treatment. Your child's primary care provider can help determine if it is a "real" eye crossing or "pseudo" eye crossing, but an eye specialist can do a more thorough exam and determine treatment and follow up requirements. If you have pictures that show your child's eyes crossing, bring them to your appointment.

5. A bump on the eye will go away. See also "stye," "pinguecula,"and "pterygium" above. In addition to sties and chalazia, hemangiomas (collections of blood vessels), lymphangiomas (collections of lymph tissues) and dermoids (cysts) can cause masses around the eye. These should be followed by a pediatric ophthalmologist. Rhabdomyosarcomas are cancerous tumors that also require immediate treatment.

6. One eye is bigger, but it's a family trait.  An eye specialist should always evaluate the eye urgently if one seems bigger than the other. There are many causes, and many need emergent or urgent treatment.

7. Glasses worsen a child's prescription.  I have heard this often from parents, worried that the glasses prescribed to their child will worsen the vision over time. This is not only incorrect thinking, but opposite of what sometimes happens. Children's eyes and nerves are developing, and early vision correction will often improve vision over time. And they can see better to avoid injury, learn better, and in general see the world better!

8. Abnormal light reflexes are just a bad picture.  When a child's "red eye" looks more white, it can be simply the angle of the lighting or the child's eye pigments, but it can be a signal of eye tumor, cataracts, or abnormal eye shape (which leads to vision problems). Never ignore this! If your child's eyes don't look right in a picture, bring the picture to an appointment with an eye care specialist.

9. Different colored eyes are cute. This can be normal, but if eyes are a different color (either left vs right or colored stripes or rings within the same eye as in the picture) a vision check by an eye specialist is a good idea.

photo source: http://en.wikipedia.org/wiki/File:Heterochromia_Blue_Orange.png

10. Parents don't know best. What an obvious myth!