Reasoning GP · Algorithm · 1-page summary
Eye swelling — periorbital and eyelid
For: adults and children with eyelid or periorbital swelling in primary care. Not for: a red eye without lid swelling, or facial swelling beyond the eye (use the red eye or facial swelling algorithm). Local antimicrobial and ophthalmology pathways take precedence.
Core rule: check vision, pupils (RAPD), eye movements and proptosis in every swollen eye. Any orbital sign means orbital pathology until proven otherwise, and no proptosis does not exclude orbital cellulitis.
0Stop — call 999 now — emergency transfer
- Airway angio-oedema (tongue, floor of mouth, hoarse voice, dysphagia, stridor) or suspected anaphylaxis → 999. IM adrenaline at once for anaphylaxis. ACE-inhibitor or hereditary angio-oedema does not respond to adrenaline.
- Suspected orbital cellulitis: infected lid plus any orbital sign — proptosis, painful or restricted eye movements, reduced vision, RAPD, chemosis, diplopia — or systemic toxicity → 999
- Cavernous sinus thrombosis (severe headache, high fever, bilateral proptosis, cranial nerve III/IV/VI palsies, altered consciousness) or rapidly spreading swelling with black eschar or severe facial pain in DKA or marked immunosuppression → 999
- Do not delay referral to get CT or MRI; imaging, blood cultures and IV antibiotics are hospital-led.
1Triage — orbital signs first
| Finding | Action |
|---|---|
| Orbital sign + infection | Suspected orbital cellulitis → 999 |
| Orbital sign, no infection | TED, tumour, fistula → Same-day hospital / ophthalmology |
| Hot red lid, eye normal | Pre-septal. Mild, well adult → block 5. Unwell, immunocompromised, unsure → Same-day. Child → Same-day paediatric advice |
| Lid lump or bilateral puffiness | Stye, chalazion, dacryocystitis, allergy, systemic oedema → block 4 |
2Screen — one row is enough
- Sight-threatening TED: reduced VA or colour vision, field loss, RAPD, corneal exposure, globe subluxation → Eye casualty now (999 if not available).
- Pulsatile proptosis + bruit (carotid-cavernous fistula) → Same-day
- Child, fever or unwell, or orbit not excluded → Same-day paediatrics
- Persistent one-sided proptosis, no infection → Ophthalmology ≤1 week; child → very urgent.
- Lid lesion: SCC or melanoma → Suspected cancer pathway; BCC → non-urgent (periocular may be high-risk).
- Known cancer → Same-day. Diabetes or immunosuppression → low threshold for hospital.
3Assess — every eye swelling
☐ VA each eye ☐ Pupils, swinging torch for RAPD ☐ Eye movements, diplopia ☐ Proptosis (look from above) ☐ Lid closure, chemosis, lid margin ☐ Temperature, pulse, BP ☐ Mark the erythema edge
Cannot check VA or RAPD → lower threshold for same-day referral. Tests: TFTs + TRAb (TED); TFTs, albumin, urinalysis, U&E (puffiness). No CT/MRI in primary care.
4Classify — only if blocks 0–2 are negative
- Pre-septal cellulitis — warm, tender, red lid; eye movements, globe and VA normal. Bite, skin, dental or sinus source.
- Stye / chalazion — tender lump at lid margin / painless firm lump in tarsal plate.
- Dacryocystitis — tender swelling below medial canthus, epiphora → local antibiotics + ophthalmology advice.
- Allergy / angio-oedema — itchy bilateral puffiness; angio-oedema non-itchy, non-pitting. ACE inhibitor?
- TED — lid retraction, proptosis, upgaze restriction; can be euthyroid. Systemic — morning puffiness: hypothyroid, nephrotic.
- Uncertain — orbital involvement not excluded → Same-day hospital; lid lesion → ophthalmology.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Mild pre-septal, adult, well, eye normal: co-amoxiclav 500/125 mg TDS for 7 days (NG141); penicillin allergy → clarithromycin with metronidazole per local guidance. Review 24–48 h.
- Stye, chalazion, blepharitis: warm compresses, lid hygiene; no routine antibiotics; do not squeeze.
- Allergic: non-sedating antihistamine, cool compress. ACE-inhibitor angio-oedema: stop, never restart any; advice before an alternative.
- TED: stop-smoking support, stable euthyroidism, lubricants.
6Refer routinely
- ≤1 week ophthalmology: suspected TED; complicated dacryocystitis; recurrent or atypical chalazion.
- Routine: uncontrolled blepharitis; chalazion troublesome after several weeks; tear-duct obstruction.
- Immunology: recurrent angio-oedema with no trigger, or ACE-inhibitor angio-oedema.
7Never reassure by
- No proptosis — it does not exclude orbital cellulitis, especially in children.
- Normal thyroid function — TED can be euthyroid.
- Feeling better while the redness spreads past the pen mark.
- A "recurrent chalazion" or one-sided "blepharitis" — think sebaceous carcinoma.
- An examination without VA, pupils and eye movements.
- Absent itch or urticaria in angio-oedema — bradykinin type still threatens the airway.
8Safety-net — in writing, then document it
999 “Call 999 or go to A&E now for pain moving your eye, difficulty moving it, the eye bulging, blurred or double vision, a severe headache, vomiting, confusion or fever with the swelling, redness spreading despite antibiotics, or swelling of the tongue or throat or noisy breathing.”
Same day: “No better after 24–48 hours of antibiotics — contact us today.” TED: loss of vision or colour vision, new double vision, eye pain or cannot close the eyes → eye casualty now.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
VA, pupils, eye movements and proptosis recorded
One diagnosis fits, or uncertainty referred
Pre-septal: edge marked, review in 24–48 h booked
Written safety-net given
Summary of the full Reasoning GP eye swelling algorithm, which holds the detail, examination and evidence. Sources: NICE NG141, NG12 (updated April 2026), NG258; Resuscitation Council UK anaphylaxis (2021); MHRA (ACE-inhibitor angio-oedema); EUGOGO (2021); Royal College of Ophthalmologists; College of Optometrists. Clinical reference — local pathways take precedence; check doses: NICE/SPC, BNF.