Eye Swelling Algorithm

Safety

Red Flags — Orbital Cellulitis, Angio-oedema & Malignancy

Done

Any orbital sign (proptosis, restricted or painful eye movement, reduced vision, RAPD, chemosis, diplopia) suggests post-septal/orbital pathology and requires same-day hospital assessment; infection is not the only cause. Orbital cellulitis is sight- and life-threatening — intracranial extension can kill.

999 / emergency transfer: airway-threatening angio-oedema (tongue, floor-of-mouth or laryngeal swelling, hoarse voice, dysphagia, stridor, respiratory difficulty) · suspected anaphylaxis with airway, breathing or circulation compromise (IM adrenaline immediately per Resuscitation Council UK — do not delay for antihistamines, corticosteroids or IV access) · suspected cavernous sinus thrombosis · suspected orbital cellulitis with visual loss, RAPD, severe pain, proptosis, ophthalmoplegia, systemic toxicity or intracranial features · sight-threatening TED · rapidly progressive swelling with black eschar or severe facial pain in DKA or marked immunosuppression.

Same-day hospital/ophthalmology: any new proptosis · restricted or painful eye movements · reduced or newly changed visual acuity · RAPD · significant chemosis · new diplopia · inability to close the eye with corneal exposure · rapidly progressive orbital swelling · suspected orbital abscess, tumour or carotid-cavernous fistula · pre-septal cellulitis that is systemically unwell, immunocompromised or diagnostically uncertain · any child in whom orbital involvement cannot be confidently excluded. Do not delay referral to obtain CT or MRI in primary care.

Proptosis (eye pushed forward) + restricted eye movement Suspected post-septal/orbital pathology — orbital cellulitis (infection posterior to the orbital septum) if infective features, but consider TED, tumour and carotid-cavernous fistula → same-day hospital; suspected orbital cellulitis → 999 / emergency transfer (imaging, blood cultures and IV antibiotics are hospital-led). Risk of cavernous sinus thrombosis, meningitis, subdural empyema, blindness. Most common after sinusitis (ethmoid sinus adjacent to orbit).

Chemosis (conjunctival oedema) + pulsatile proptosis + bruit Carotid-cavernous sinus fistula (post-trauma or spontaneous) → same-day neuroradiology/ophthalmology. Arterial blood shunting into orbital venous system causes pulsating exophthalmos and conjunctival injection.

Unilateral proptosis + diplopia + no infection signs Orbital tumour (lymphoma, lacrimal gland tumour, metastasis, rhabdomyosarcoma in children) → new proptosis or new diplopia: same-day hospital/ophthalmology; persistent, stable proptosis without acute features: urgent ophthalmology / oculoplastic referral (local pathway; an adult orbital tumour is not an NICE NG12 criterion — a child needs very urgent specialist assessment) Imaging is specialist-led. Also consider with a firm orbital or lacrimal-gland mass, unexplained visual change, recurrent "cellulitis" without convincing infection, or known cancer/immunosuppression. Unexplained adult unilateral proptosis needs urgent assessment for orbital pathology — including TED (a common adult cause), inflammation, vascular disease and tumour.

Rapidly progressive bilateral proptosis + lid retraction + conjunctival injection Severe thyroid eye disease (TED) with compressive optic neuropathy — loss of colour vision, reduced visual acuity, relative afferent pupillary defect (RAPD), visual-field symptoms, corneal breakdown, inability to close the eyelids or sudden globe subluxation → emergency eye-casualty assessment now (999 / emergency transfer if not immediately available). Risk of permanent sight loss.

Eye swelling + lip/tongue/throat swelling Angio-oedema with airway compromise risk → 999. ACE inhibitor-induced or hereditary (C1-esterase inhibitor deficiency). Airway symptoms: 999 and IM adrenaline (Resuscitation Council UK dose) if anaphylaxis is suspected; bradykinin-mediated angio-oedema (ACE inhibitor, HAE) does not respond to adrenaline and needs urgent airway management and specialist treatment. Periorbital angio-oedema without airway symptoms: treat by mechanism — no routine prednisolone.

Periorbital swelling in a child + fever + unwell Orbital cellulitis is a paediatric emergency — children can deteriorate rapidly. Pre-septal cellulitis in children also warrants careful assessment (orbital involvement harder to exclude clinically in children). Same-day paediatrics if systemically unwell, orbital involvement cannot be excluded, severe swelling, significant pain, rapid progression, immunosuppression, recurrent disease or diagnostic uncertainty — otherwise same-day paediatric or specialist advice for any child with pre-septal cellulitis (local paediatric pathway).

Eyelid mass + progressive growth, ulceration or bleeding Eyelid malignancy: basal cell carcinoma (most common — firm, pearly, telangiectatic margin), squamous cell carcinoma, sebaceous gland carcinoma (aggressive — may mimic recurrent chalazion or persistent unilateral "blepharitis"), melanoma. Also lash loss, induration, lid distortion or recurrence at the same site. NICE NG12: suspected BCC → non-urgent referral; suspected SCC or melanoma → urgent suspected-cancer pathway. Periocular location may make a lesion high-risk — oculoplastic/skin-cancer referral.

Periorbital swelling + headache + meningism Cavernous sinus thrombosis (complication of orbital/facial infection) — severe headache, high fever, bilateral proptosis, CN III/IV/VI palsies, altered consciousness or bilateral orbital signs → 999.

Orbital cellulitis is one of the most dangerous eye emergencies in primary care — the hallmark distinguishing it from pre-septal (periorbital) cellulitis is involvement posterior to the orbital septum, which communicates directly with the intracranial venous sinuses via the superior and inferior ophthalmic veins. The orbital septum is a thin fibrous membrane extending from the bony orbital rim to the eyelid tarsal plates — it is the critical anatomical barrier. Structures anterior to it (eyelid skin, pre-septal fat) can be infected without danger to vision or life. Structures posterior to it (orbital fat, extraocular muscles, optic nerve) cannot. The Chandler classification of orbital infections grades severity: Class I (inflammatory oedema) through Class V (cavernous sinus thrombosis). Class II upwards (subperiosteal abscess or beyond) requires IV antibiotics and urgent imaging. The cardinal signs of orbital (vs pre-septal) disease are: proptosis (forward displacement of the globe), ophthalmoplegia (restricted eye movement from myositis or mechanical tethering), pain on eye movement, and reduced visual acuity. Any one of these in a patient with periorbital swelling mandates same-day hospital assessment — but they suggest post-septal/orbital pathology rather than proving infection, and can also occur in thyroid eye disease, orbital tumour and carotid-cavernous fistula. Absence of proptosis does not exclude orbital cellulitis, especially in children or early disease.

Diagnose

Pre-septal vs Post-septal — The Critical Distinction

Done

Examine every periorbital swelling for orbital signs. Any orbital sign suggests post-septal/orbital pathology and requires same-day hospital assessment; infection is not the only cause.

Pre-septal (periorbital cellulitis)

Infection anterior to orbital septum — manageable in primary care only if mild, the diagnosis is secure and the patient is suitable. Features: eyelid erythema + swelling, tender to palpation, may be hot. Crucially: normal eye movement (full range), no proptosis, normal visual acuity, no pain on eye movement, no RAPD. Usually follows skin infection, insect bite, conjunctivitis, minor trauma, or sinus, dental or lacrimal sources. Marking the edge of erythema assists follow-up. Oral antibiotics in mild cases.

Post-septal (orbital cellulitis)

Infection posterior to orbital septum — vision- and life-threatening. Orbital signs — any one = suspected post-septal/orbital pathology (infection, TED, tumour or vascular cause): (1) Proptosis (forward globe displacement), (2) Ophthalmoplegia (restricted eye movement — pain on moving eye), (3) Chemosis (conjunctival oedema — swollen pink conjunctiva bulging forward), (4) Reduced visual acuity, (5) RAPD (relative afferent pupillary defect — afferent pupil defect on swinging torch test = optic nerve involvement), (6) Diplopia. Suspected orbital cellulitis → 999 / emergency transfer; other orbital pathology → same-day hospital. Fever/systemic illness is more concerning if present. Absence of proptosis does not exclude orbital cellulitis, especially in children or early disease.

Proptosis assessment

Compare eye protrusion by standing behind patient and looking from above — asymmetric forward globe position = proptosis. Exophthalmometer (Hertel) measures formally. Any new proptosis in a patient with periorbital swelling = orbital pathology until proven otherwise (not proof of infection) → same-day assessment.

Visual acuity check

Mandatory in all periorbital swellings — use Snellen chart or near vision card. Document VA each eye separately. Any reduction in VA in the context of periorbital swelling = orbital involvement until proven otherwise — this mandates same-day hospital assessment rather than proving cellulitis. If VA or RAPD cannot be assessed in primary care, lower the threshold for same-day referral rather than delay it. Compare with patient's baseline (spectacles prescription on phone, previous records).

RAPD (relative afferent pupillary defect)

Swinging torch test: shine bright torch into one eye for 2 seconds, then swing to the other. Normal: both pupils constrict equally. RAPD: pupil dilates (rather than constricts) when light swings to the affected eye = optic nerve compression. RAPD in orbital swelling = compressive optic neuropathy → 999.

History

Onset and speed of progression · unilateral or bilateral · pain, particularly on eye movement · blurred or reduced vision, altered colour perception, visual-field loss or diplopia · fever, malaise, headache, vomiting or meningism · sinusitis, dental or skin infection, insect bite, trauma or recent surgery · contact-lens use · allergy, urticaria, food or drug exposure · ACE inhibitor, ARB, NSAID, DPP-4 inhibitor or oestrogen exposure · Graves' disease, thyroid dysfunction and smoking · recurrent non-urticarial swellings, abdominal pain or family history of angio-oedema · duration and recurrence of an eyelid lump · skin cancer, immunosuppression or previous malignancy.

The swinging torch test (RAPD assessment) is one of the most important and underused clinical skills in primary care — it can be performed quickly with any bright torch and directly tests optic nerve function. A positive RAPD means that the affected optic nerve is conducting fewer signals to the brain despite being illuminated — the brain therefore interprets the affected eye as "seeing" less light, and drives pupillary dilation rather than constriction when the light swings to that eye. In the context of periorbital swelling, an RAPD indicates optic nerve compression from an orbital abscess, tumour, or the swollen tissues of severe thyroid eye disease. It is a genuine ocular emergency. Visual acuity measurement with a Snellen chart should be performed at every GP consultation involving an eye complaint — it is quick, requires no equipment beyond the chart on the wall or a phone app (Peek Acuity), and provides objective baseline data. Many cases of delayed diagnosis of serious ophthalmic conditions involve the absence of documented visual acuity at the primary care presentation.

Diagnose

Differential Diagnosis — Non-Emergency Causes

Done

Chalazion (meibomian cyst)

Most common eyelid lump. Painless, firm, non-tender rounded swelling in the eyelid (within tarsal plate — not at lid margin). Non-infective inflammatory lesion from meibomian-gland obstruction. No systemic illness or orbital signs. Warm compresses and gentle lid massage; antibiotics are not required for an uncomplicated chalazion, even when large. Refer if persistent and troublesome despite several weeks of conservative treatment, recurrent at the same site, atypical, ulcerated, associated with lash loss or lid distortion, or diagnostic uncertainty. Recurrent or atypical lesions → ophthalmological assessment and often biopsy (sebaceous carcinoma or other tumour).

Hordeolum (stye)

Acute painful tender red lump at eyelid margin. External (stye = infected lash follicle / Zeis gland — points at lid margin) or internal (infected meibomian gland — points towards conjunctiva). Often staphylococcal. Warm compresses for around 5–10 minutes several times daily + gentle lid hygiene. Most drain spontaneously. Do not squeeze or puncture. Topical antibiotics are not routinely required unless there is clinically indicated secondary infection or associated conjunctivitis. Refer if unusually large, persistent, recurrent in the same location, associated with cellulitis or causing visual symptoms.

Pre-septal (periorbital) cellulitis

Eyelid erythema, warmth, swelling, tenderness. No orbital signs. Common in children after insect bite, minor skin trauma, or as spread from conjunctivitis / dacryocystitis. Adults: dental abscess (medial spread), sinus disease. Mild, well, diagnosis secure: oral co-amoxiclav 500/125 mg TDS × 7 days (NICE NG141). Systemically unwell, immunocompromised or uncertain → same-day assessment. Children: same-day paediatric or specialist advice (local paediatric pathway).

Dacryocystitis (lacrimal sac infection)

Painful red swelling below medial canthus (lower medial orbit) — infection of the nasolacrimal sac. Tearing (epiphora), discharge, swelling tender at lacrimal fossa. Acute: prompt medical treatment (per local antimicrobial guidance) and ophthalmology advice, particularly if systemic illness, abscess formation, recurrent disease or failure to improve (may need sac washout / dacryocystorhinostomy). Can progress to periorbital or orbital cellulitis.

Allergic reaction

Bilateral puffy eyelids with itch, no erythema or warmth, associated with other allergic features (rhinitis, urticaria, sneezing). Angioedema: asymmetric, non-itchy, non-pitting, rapid onset (minutes to hours). Seasonal allergic conjunctivitis: bilateral, seasonal, chemosis (conjunctival swelling), watery discharge. No warmth, focal tenderness, proptosis or visual loss. Allergen avoidance, cool compresses, non-sedating oral antihistamine + appropriate topical ocular treatment if conjunctivitis is present.

Thyroid eye disease (TED)

Bilateral proptosis (may be asymmetric), lid retraction (white sclera visible above cornea = "stare"), lid lag, periorbital oedema, conjunctival injection, restricted eye movement (inferior rectus fibrosis → upgaze restriction). Also dry or gritty eyes and diplopia. Associated with Graves' disease (may precede, accompany, or follow hyperthyroidism) and may occur with euthyroid biochemistry. TFTs (+ TSH receptor antibodies where available). Refer suspected TED to ophthalmology or a combined thyroid-eye service (except the mildest cases clearly improving with euthyroidism and local treatment). Sight-threatening features (reduced VA, impaired colour vision, visual-field loss, RAPD, corneal exposure, globe subluxation) → emergency eye-casualty assessment now (999 / emergency transfer if not immediately available).

Blepharitis

Chronic bilateral eyelid margin inflammation — lid margin thickening, crusting at lash bases, collarettes around lashes. Burning, grittiness, intermittent blurring, dry eye. Associated with rosacea and seborrhoeic dermatitis. Management: long-term daily lid hygiene (warm compress + lid scrub) + lubricant eye drops; manage rosacea or seborrhoeic dermatitis. Not curable but controllable. Topical or oral antibiotics, topical corticosteroids and doxycycline reserved for selected cases, usually after review and/or ophthalmology advice.

Periorbital oedema (systemic)

Bilateral morning periorbital puffiness — hypothyroidism (myxoedema), nephrotic syndrome, allergy, venous/lymphatic obstruction (SVC syndrome — facial + arm oedema), angioedema. Check TFTs, albumin, urinalysis, renal function. Periorbital oedema is often the first visible sign of nephrotic syndrome (periorbital loose connective tissue fills with fluid first) and hypothyroidism.

Recurrent chalazion deserves specific clinical attention — a chalazion that recurs at the same site should raise suspicion for sebaceous gland carcinoma (SGC), a rare but aggressive eyelid malignancy that classically masquerades as a recurrent or treatment-resistant chalazion. SGC arises from the meibomian glands or Zeis glands and has a pagetoid spread pattern (intraepithelial spread along the conjunctiva without visible mass). Recurrent, atypical or suspicious lesions require ophthalmological biopsy/histology, following the ophthalmology and local pathology pathway. GPs should document chalazion location and refer any recurrence to ophthalmology. Thyroid eye disease (TED) is the most common cause of bilateral proptosis and unilateral proptosis in adults — it is directly caused by TSH receptor antibody-driven glycosaminoglycan deposition in the orbital fat and extraocular muscles, causing volume expansion within the rigid bony orbit. Importantly, TED can occur when thyroid function tests are normal (euthyroid Graves' disease) — TFTs alone do not exclude TED as the cause of proptosis.

Diagnose

Targeted Examination & Investigations

Done

Mandatory checks (all eye swelling)

Visual acuity (Snellen or near card, each eye separately) · Pupil reactions including RAPD (swinging torch) · Eye movements (all 6 directions — restriction indicates orbital involvement) · Proptosis (compare eyes from above) · Eyelid opening / ptosis · Ability to close the eyelids and corneal exposure · Conjunctival inspection (chemosis, injection, discharge) · Diplopia and colour vision if concern about optic nerve involvement · Eyelid margin: lash loss, ulceration, telangiectasia, pigmentation · Thyroid signs: lid retraction, lid lag

Lump characterisation

Location: eyelid margin (stye, keratosis, papilloma), within tarsal plate (chalazion), medial canthus (dacryocystitis), lateral upper lid (lacrimal gland enlargement — lymphoma, sarcoid), diffuse eyelid (cellulitis, allergy, systemic oedema). Consistency: firm non-tender (chalazion), fluctuant tender (abscess / stye), hard irregular (malignancy). Skin changes: pearly / telangiectatic (BCC), pigmented (melanoma).

Systemic examination

Temperature, pulse, blood pressure and general appearance (cellulitis / orbital cellulitis — systemic sepsis). Dental and facial skin findings. Neck lymphadenopathy (ENT source, lymphoma). Thyroid examination (goitre, thyroid bruit — TED). Skin rosacea (blepharitis association). Sinus tenderness (sinusitis → orbital cellulitis source).

Investigations (directed)

TFTs + TSH receptor antibodies (thyroid eye disease) · FBC + CRP + ESR (cellulitis, orbital cellulitis — guides severity) · Blood cultures (pre-antibiotic in orbital cellulitis — hospital) · CT orbits + sinuses (orbital cellulitis — defines abscess, sinus source — hospital) · MRI orbits (soft tissue — orbital tumour, optic nerve, extraocular muscle) · C4 + C1-INH antigen + C1-INH function (suspected hereditary angio-oedema — specialist-directed; normal C4 alone does not exclude HAE, particularly between attacks; confirm abnormal results). Do not delay referral to obtain CT or MRI in primary care.

Nasolacrimal system

Assess in all medial eyelid swellings: press over lacrimal sac (below medial canthus) — regurgitation of mucopurulent discharge confirms nasolacrimal duct obstruction / dacryocystitis. Epiphora (excessive tearing) suggests nasolacrimal obstruction. Referral to ophthalmology for sac washout or dacryocystorhinostomy (DCR).

CT orbits with contrast is the definitive investigation for orbital cellulitis — it identifies subperiosteal abscess (collection between the bony orbital wall and periorbita, typically medial from ethmoid sinusitis), intraorbital abscess, and intracranial extension. The decision to proceed to CT should be made in hospital after initial clinical assessment, not in primary care (where CT is not available). The key primary care role is to recognise the clinical signs of orbital involvement and refer the same day for emergency hospital assessment — attempting to definitively exclude orbital cellulitis in primary care by clinical examination alone is unsafe and is associated with delayed diagnosis. The TSH receptor antibody (TRAb) test is the most specific investigation for thyroid eye disease — it is usually positive in active TED, even when TFTs are normal (euthyroid Graves'). A positive TRAb with periorbital swelling and any of the features of TED (lid retraction, proptosis, restricted eye movement) supports the diagnosis and warrants ophthalmology referral. TRAb is not routinely available in all GP laboratories — check local availability and if unavailable, refer on clinical suspicion.

Refer

Referral Pathways

Done

999

Suspected orbital cellulitis with visual loss, RAPD, severe pain, proptosis, ophthalmoplegia, systemic toxicity or intracranial features (meningism, headache, bilateral signs, confusion) · Airway-threatening angio-oedema (tongue, floor of mouth, larynx, hoarse voice, dysphagia, stridor) or suspected anaphylaxis · Cavernous sinus thrombosis (bilateral proptosis + fever + CN palsies + headache) · Sight-threatening TED · Rapidly progressive swelling with black eschar or severe facial pain in DKA or marked immunosuppression

Same-day ophthalmology / A&E

Any orbital sign (new proptosis, restricted or painful eye movement, chemosis, reduced or changed VA, RAPD, new diplopia) → same-day hospital. Inability to close the eye with corneal exposure. Rapidly progressive orbital swelling. Pre-septal cellulitis that is systemically unwell, immunocompromised or diagnostically uncertain. Any child in whom orbital involvement cannot be confidently excluded. Suspected orbital abscess, orbital tumour with acute visual change, or carotid-cavernous fistula (pulsatile proptosis + bruit).

Urgent ophthalmology (within 1 week)

Suspected TED (ophthalmology or combined thyroid-eye service) · Dacryocystitis with systemic illness, abscess, recurrence or failure to improve · Recurrent or atypical chalazion at same site (biopsy) · Suspected eyelid malignancy (SCC/melanoma → urgent suspected-cancer pathway; BCC → non-urgent per NICE NG12; periocular lesions may be high-risk) · Persistent or progressive unilateral proptosis without infection → urgent ophthalmology/oculoplastics

Ophthalmology (routine)

Chronic blepharitis not controlled with lid hygiene · Chalazion persistent and troublesome despite several weeks of conservative treatment · Nasolacrimal duct obstruction (epiphora) · Mild TED — monitoring programme · Entropion / ectropion causing recurrent blepharitis

Endocrinology

New Graves' disease with TED — joint management with ophthalmology. Aim for stable euthyroidism, avoiding both untreated hyperthyroidism and iatrogenic hypothyroidism. Smoking worsens TED and reduces treatment response — offer intensive cessation support.

Immunology / allergy

Recurrent angio-oedema without identifiable trigger (possible hereditary angio-oedema — C1-INH deficiency) · Severe persistent allergic periorbital swelling not responding to standard antihistamines · Suspected ACEi-induced angio-oedema (document permanently on record; seek advice before selecting an alternative antihypertensive) · Do not initiate icatibant, C1-inhibitor concentrate or long-term tranexamic acid without an established specialist plan

Thyroid eye disease requires dual-specialty management — ophthalmology for the orbital component and endocrinology for thyroid function optimisation. The relationship between thyroid disease activity and TED activity is imperfect — TED can be active when thyroid function is controlled, and can progress after radioactive iodine treatment (RAI). EUGOGO (European Group on Graves' Orbitopathy) guidelines note that RAI treatment worsens TED in smokers and those with moderate-severe TED — in these patients, thyroidectomy or antithyroid drugs are preferred over RAI. Smoking worsens TED and reduces treatment response (EUGOGO) — offer intensive smoking cessation support to every patient with Graves' disease. This should be documented at every consultation. Dacryocystitis is a condition that GPs frequently under-refer — acute dacryocystitis (lacrimal sac infection) causes medial canthal swelling and can track both pre-septally into the eyelid and post-septally into the orbit. Acute dacryocystitis requires prompt medical treatment and ophthalmology advice, particularly if there is systemic illness, abscess formation, recurrent disease or failure to improve.

Treat

GP-Initiated Treatment

Done

Pre-septal cellulitis (mild, adult)

Co-amoxiclav 500/125 mg TDS × 7 days (NICE NG141)

Only when the diagnosis is secure, the patient is systemically well, VA and eye movements are normal, there is no proptosis, diplopia, RAPD or significant chemosis, and the patient can be reviewed with reliable safety-netting. Check local formulary equivalence, renal function and penicillin allergy. True penicillin allergy or co-amoxiclav unsuitable: follow local antimicrobial guidance — NICE lists clarithromycin with metronidazole for infection near the eyes or nose (do not use co-trimoxazole routinely). Consider specialist advice for infection near the eye. Review clinically within 24–48 hours, or sooner if worsening; seek help if worsening rapidly or not improving within 2–3 days. Children: age/weight-appropriate prescribing; same-day paediatric/specialist advice for every child, and same-day paediatric assessment if systemically unwell, orbital involvement cannot be excluded, severe swelling, significant pain, rapid progression, immunosuppression, recurrent disease or diagnostic uncertainty — not every mild pre-septal cellulitis needs IV antibiotics.

Stye (hordeolum)

Warm compresses + lid hygiene

Tolerably warm (not hot) compress applied to the closed eyelid for around 5–10 minutes, several times daily, softens the secretions and encourages spontaneous drainage; gentle lid hygiene. Topical antibiotics are not routinely required — only for clinically indicated secondary infection or associated conjunctivitis. Do NOT squeeze or puncture the lesion — causes spread. Recurrent styes: blepharitis treatment + lid hygiene.

Allergic periorbital swelling

Non-sedating oral antihistamine

Oral antihistamine (cetirizine or loratadine — non-sedating). Topical antihistamine eye drops (olopatadine 0.1% — Opatanol, or azelastine) for associated allergic conjunctivitis. Cold compress for immediate relief. Topical sodium cromoglicate 2% (Opticrom) — mast cell stabiliser, preventive use. Seasonal: start 2 weeks before predicted season. Avoid known allergens.

ChalazionWarm compresses and gentle lid massage. No routine antibiotics or steroid–antibiotic combinations, even when large. Persistent and troublesome despite several weeks of conservative treatment → ophthalmology (options include incision and curettage). Recurrent, atypical or suspicious lesions require ophthalmological biopsy/histology.

BlepharitisLong-term lid hygiene: (1) Warm compress using a safe, tolerably warm proprietary lid-warming device or clean warm compress (avoid hot flannels that could scald) → (2) Gentle lid massage where meibomian gland dysfunction is present → (3) Lid-margin cleansing (proprietary lid wipe or cotton bud) daily. Lubricants (e.g. hypromellose) for associated dry eye. Manage rosacea or seborrhoeic dermatitis. Topical or oral antibiotics, topical corticosteroids and doxycycline reserved for selected cases (significant MGD/ocular rosacea), usually after review and/or ophthalmology advice. Blepharitis is chronic — controlled rather than permanently cured.

Angio-oedema (non-airway)Treat by mechanism. Histamine-mediated (itch, urticaria, rapid onset after exposure, responds to antihistamine): non-sedating antihistamine; a short oral corticosteroid course only occasionally for severe histaminergic disease, not automatically. Bradykinin-mediated (ACE inhibitor, hereditary or acquired C1-inhibitor deficiency; no urticaria or itch; slower progression; poor response to antihistamines, steroids or adrenaline): if ACEi suspected, stop it immediately, document clearly and never restart any ACE inhibitor; assess airway; seek advice before selecting an alternative — an ARB may be considered individually but is not risk-free and not an automatic substitution. Adrenaline auto-injectors are not routinely indicated for isolated non-histaminergic angio-oedema (consider after specialist assessment for true anaphylaxis or recurrent severe airway-threatening histaminergic disease). Icatibant 30 mg SC (bradykinin B2 antagonist) is licensed for hereditary angio-oedema; a phase III RCT found no benefit over placebo in ACEi-induced angio-oedema (Sinert et al., 2017). Suspected HAE (recurrent non-urticarial swelling, abdominal attacks, childhood/adolescent onset, laryngeal episodes, family history): specialist-directed C4, C1-INH antigen and function. Do not initiate icatibant, C1-INH concentrate or long-term tranexamic acid without an established specialist plan.

The warm compress technique for chalazion and blepharitis works by liquefying the solidified meibum (meibomian gland secretion) that blocks the gland orifice. A safe, tolerably warm compress applied for around 5–10 minutes softens the secretions, and the subsequent lid massage physically expresses them. Proprietary lid-warming devices give more consistent heat; avoid hot flannels likely to scald the skin. Doxycycline for blepharitis acts mainly via anti-inflammatory and anti-lipase properties; it is reserved for selected cases, usually after review and/or ophthalmology advice, rather than prescribed routinely.

Treat

Thyroid Eye Disease — GP Role

Done

Smoking cessation

Smoking worsens TED and reduces treatment response. Document smoking status at every TED consultation. Offer intensive smoking cessation support (pharmacotherapy + behavioural support) — refer to Stop Smoking Service.

Thyroid function optimisation

Arrange thyroid function testing and endocrine assessment. Aim for stable euthyroidism — avoid both untreated hyperthyroidism and iatrogenic hypothyroidism. Antithyroid drug regimens (including block-and-replace) are endocrinology-led, not routine GP-initiated treatment.

Moderate-severe active TED

Specialist hospital treatment only — IV methylprednisolone, orbital radiotherapy, biologic treatment and surgery are specialist interventions, not GP treatment protocols. GP role: referral, stable euthyroidism, smoking cessation, lubricants and safety-netting.

Selenium supplementation

Selenium may be considered for selected mild, active, recent-onset TED, particularly where selenium deficiency is relevant (EUGOGO) — usually on specialist advice. Do not prescribe indiscriminately for all patients with TED; consider local selenium status, interactions and toxicity.

Corneal protection

Lid lag → corneal exposure → corneal ulceration risk. Preservative-free lubricant eye drops as needed. Night-time lubricant gel/ointment where indicated. Eye taping at night if lagophthalmos (incomplete lid closure). Prompt ophthalmology if corneal symptoms (pain, photophobia, blurred vision).

Surgical options (ophthalmology)

Specialist-led rehabilitative surgery (after disease quiescence): (1) Orbital decompression (expands orbital volume — reduces proptosis), (2) Squint surgery (corrects diplopia from restricted muscles), (3) Lid surgery (ptosis repair, retraction correction, blepharoplasty). Order is always: decompression first, then squint, then lids.

Next steps: see Chalazion · Cellulitis and erysipelas · Angioedema · Blepharitis · Hyperthyroidism · Allergic conjunctivitis

The EUGOGO selenium trial (Marcocci et al., NEJM 2011) showed benefit in mild, active, recent-onset TED, in a population where selenium deficiency may have been relevant. EUGOGO (2021) therefore advises that selenium may be considered for selected mild, active, recent-onset disease — it should not be prescribed indiscriminately for all patients with TED, and local selenium status, interactions and toxicity should be considered. The core GP role is stable euthyroidism, smoking cessation, local ocular treatment and timely referral.

Lifestyle

Eye Health, Hygiene & Prevention

Done

Lid hygiene (blepharitis) Daily routine — non-negotiable for blepharitis and stye recurrence prevention. Tolerably warm compress (proprietary lid-warming device or clean warm compress — avoid scalding) → gentle lid massage → lid-margin cleansing (proprietary lid wipe or cotton bud). This is lifelong maintenance — blepharitis does not resolve permanently.

Contact lens hygiene Contact lens wearers with periorbital or ocular swelling: remove lenses immediately and do not reinsert until symptom-free. Contact lens wear is the primary risk factor for Acanthamoeba keratitis and microbial keratitis — red eye + pain + contact lens use = urgent ophthalmology (not GP management). No swimming in contact lenses. Monthly replacement, correct solution use.

Allergy avoidance Seasonal allergic eye disease: sunglasses (reduces airborne allergen exposure), shower on returning home (washes pollen from hair and face), avoid eye rubbing (worsens mast cell degranulation + risk of keratoconus), antihistamine eye drops 2 weeks pre-season. Perennial allergy: HEPA filter, house dust mite covers, pet avoidance.

TED — UV protection Proptosis and incomplete lid closure expose the cornea to drying and UV damage. Wrap-around UV-blocking sunglasses outdoors — reduces photophobia and corneal UV exposure. Dark-tinted glasses also reduce visibility of proptosis (psychological benefit — significant body image impact of TED). UV400 protection recommended.

Screen use and dry eye Screen use reduces blink rate, causing evaporative dry eye which worsens blepharitis and meibomian gland dysfunction. 20-20-20 rule: every 20 minutes, look at something 20 feet away for 20 seconds (allows full blink cycle). Preservative-free lubricant drops before prolonged screen use.

Smoking (TED and orbital health) Smoking worsens TED and reduces treatment response, and impairs wound healing after eyelid surgery. In TED patients: offer intensive cessation support — refer to Stop Smoking Service.

Recurrent chalazion prevention Lid hygiene reduces chalazion recurrence by reducing meibomian gland blockage. Omega-3 supplements or doxycycline for recurrent chalazia are specialist/individualised treatments only — evidence is not sufficient for routine GP prescribing.

Immunocompromised patients Diabetics, immunosuppressed, and elderly: lower threshold for hospital referral in any periorbital swelling — infection can progress rapidly, orbital complications are more common, and organisms may be atypical (mucormycosis — invasive fungal sinusitis invading orbit in diabetic ketoacidosis → devastating prognosis). Rapidly worsening periorbital swelling in DKA or marked immunosuppression → consider invasive fungal sinusitis and arrange immediate hospital assessment (999), particularly with severe facial pain, necrosis/black eschar, ophthalmoplegia or cranial-nerve signs.

Orbital mucormycosis is a rare but life-threatening condition that must be recognised early — it occurs in immunocompromised patients (classically diabetic ketoacidosis, but also haematological malignancy, organ transplant). The Mucorales fungi (Rhizopus, Mucor) invade the sinonasal mucosa and rapidly extend through the bony walls of the sinuses into the orbit and intracranially. It presents as rapidly progressive periorbital or facial swelling with black eschar on nasal or palatal mucosa — pathognomonic of tissue necrosis from vascular invasion. Any periorbital swelling in a diabetic who is unwell or acidotic requires same-day assessment as a matter of urgency. Treatment is hospital-led (antifungal therapy and surgical debridement) and mortality is high even with treatment. The 20-20-20 rule for screen users is a simple measure suggested in optometric advice for screen-related dry eye — reduced blink rate during screen use leads to tear film evaporation and meibomian gland hyperstimulation, directly contributing to the blepharitis-meibomian gland dysfunction spectrum.

Safety

Follow-Up & Safety-Netting

Done

Pre-septal cellulitis — 24–48 hours

Clinical review within 24–48 hours, or sooner if worsening — margin advancing beyond pen mark? Developing orbital signs (pain on eye movement, reduced VA, diplopia, proptosis, chemosis)? Any orbital sign → 999 / emergency transfer (suspected orbital cellulitis); failure to improve or diagnostic uncertainty → same-day hospital assessment. Written advice to call 999 or go to A&E immediately for pain on eye movement, reduced or blurred vision, diplopia, proptosis, increasing chemosis, severe headache, vomiting or confusion, fever or systemic deterioration, or spreading erythema despite treatment.

Stye

Resolving with warm compresses? Spontaneous drainage? Review if not improving after several weeks of regular warm compresses, unusually large, recurrent at the same site, or associated with lash loss, ulceration, lid distortion or visual symptoms → ophthalmology. Spreading cellulitis → same-day hospital. Recurrent styes in same area → rule out underlying chalazion, blepharitis (manage), or sebaceous gland carcinoma (refer).

Chalazion

Review if not improving after several weeks of regular warm compresses → ophthalmology referral. Recurrent at the same site, atypical, or with lash loss, lid distortion or visual symptoms → ophthalmology for assessment and biopsy/histology. Any change in overlying skin (ulceration, telangiectasia) → urgent ophthalmology.

Blepharitis — after several weeks

Review after a reasonable trial of lid hygiene, usually several weeks. Lid hygiene programme commenced? Symptoms improving? Blepharitis is chronic — set expectation of control not cure. Refer urgently for reduced vision, significant ocular pain, photophobia, corneal involvement or pain on eye movement. Eyelid margin telangiectasia / meibomian cysts → ophthalmology assessment.

TED — ongoing

Smoking cessation achieved? TFTs stable? Ophthalmology monitoring programme confirmed? Corneal lubricants adequate? Safety-net: reduced visual acuity, reduced colour vision, RAPD, visual-field loss, new or worsening diplopia, corneal pain, opacity or photophobia, inability to close the eyelids, or sudden increase in proptosis → emergency eye-casualty assessment now (999 / emergency transfer if not immediately available) — sight-threatening TED can deteriorate rapidly.

Angio-oedema

ACEi stopped permanently and alternative chosen after advice? Specialist-directed C4, C1-INH antigen and function if HAE suspected? Allergy/immunology referral arranged? Adrenaline auto-injector only if specialist-assessed true anaphylaxis or recurrent severe airway-threatening histaminergic disease? Written emergency action plan given? Family educated on adrenaline autoinjector use? Document permanently in medical record.

999 safety-net

Any orbital sign developing at any point (proptosis, ophthalmoplegia, reduced VA, RAPD, chemosis, diplopia) · Eye swelling with new throat/tongue swelling or stridor (angio-oedema airway) · New severe headache + orbital swelling + fever (cavernous sinus thrombosis) · Rapidly progressive swelling with black eschar or severe facial pain in DKA or marked immunosuppression (invasive fungal sinusitis)

Same-day GP

Cellulitis margin not responding to oral antibiotics at 24–48 hrs (same-day hospital) · Stye spreading to preseptal cellulitis · New diplopia in known TED patient (acute muscle involvement → emergency eye-casualty assessment now (999 / emergency transfer if not immediately available)) · Periorbital swelling in any patient with known cancer (metastasis to orbit / lymphoma) · VA change from baseline in any periorbital condition

The 24–48-hour review for pre-septal cellulitis is one of the most important safety-netting steps in GP ophthalmology — it identifies the minority of cases that progress to orbital involvement and allows early escalation before complications develop. Documenting the cellulitis margin with a pen (marking the erythema boundary with a date and time) at the first consultation provides an objective comparator at the 48-hour review — the margin should be receding or static, not advancing. Advancing margin at review = treatment failure = same-day hospital. This rule applies regardless of whether the patient feels systemically better — local progression can occur without worsening systemic symptoms. Written safety-netting instructions (either a leaflet or EyeSafe-style written advice) given to every patient with periorbital swelling should include: "If you develop pain when moving your eye, difficulty moving your eye in any direction, your eye appears to be bulging forward, your vision changes, or you develop a severe headache with fever, call 999 or attend A&E immediately." This instruction must be documented in the clinical records to meet safety-netting standards.