Patient Presentation
A 4-year-old female came to clinic with a left red eye for 2 days. The mother said that it seemed to be getting redder but denied her having any pain, rubbing of the eye, photophobia or obvious visual changes. The mother denied any trauma to the head and neck and specifically the eye that she was aware of. The patient gave the same history. The family had been working with some home cleaners around this time, but they had specifically not had her in that area of the home.
The past medical history was negative for allergies. The review of systems was negative including no fever, rashes, or masses noted.
The pertinent physical exam showed a healthy appearing female with normal growth parameters and vital signs. The patient was noted to intermittently rub both eyes but rubbed the left eye more than right. The left eye had mild generalized edema of both eyelids without erythema of the skin. There were no specific masses noted and only clear mild increased tearing. There was mild erythema of the palpebral and scleral conjunctiva, with slight elevation of the scleral conjunctiva laterally. Most of this had clear fluid, but was slightly more opaque on the lateral aspect between 2-4 o’clock. The cornea and anterior segment did not appear involved and the patient only allowed a brief glimpse of the red reflex which appeared normal. Both the anterior segment and the red reflex appeared sharp and clear. The nose had normal secretions. The mouth and ears were normal. There were some anterior cervical shotty nodes but no other enlarged lymph nodes. Skin exam was normal.
The diagnosis of a reddened left eye with chemosis was made. The pediatrician was unclear as to the reason for this unilateral erythema and edema and also was more concerned because the chemosis was somewhat opaque on the lateral aspect. As the patient did not have other specific signs or symptoms requiring immediate ophthalmological care, he opted to start the patient on oral antihistamines and refer for non-emergent examination. The ophthalmologist saw the patient 2 days later and at that time the erythema had decreased. The ophthalmologist agreed that the chemosis had been more opaque and was now improving. She also noted slight conjunctivitis of the other eye. She was unclear if this was caused by being around the chemicals from the home cleaning or some type of unidentified allergy. She prescribed antihistamine eye drops and the problem resolved within several days.
Discussion
Chemosis is edema of the eye surface membranes because of accumulation of fluid between the conjunctiva and episclera. It is usually due to allergies or infections and less likely trauma. Chemosis can be uni- or bilateral, and can be seen in one or both eyelids. There is often erythema of the eyelids and conjunctiva as well. The tissue appears thickened with usually clear fluid but opaque or solid appearing chemosis is potentially more ominous. Rarely, the swelling can be so great that the eyelids are elevated away from the globe or even cause eyelid eversion.
A differential diagnosis of red eyes can be reviewed here.
A differential diagnosis of generalized eye swelling can be reviewed here.
Learning Point
While most causes of chemosis and/or red eyes are relatively benign, more severe ophthalmologic problems always need to be considered such as iritis, keratitis, uveitis, scleritis, and glaucoma. Red flag signs include severe pain, painful pupillary reaction or anisocoria, decreased visual acuity, photophobia, or orbital signs especially that has acute onset of symptoms. If the cornea appears involved (i.e. irritated, hazy, etc.), there are anterior or posterior section abnormalities on exam or if there are neurological changes to the eye or patient overall, these need to be evaluated by opthalmology and/or other services.
Causes of chemosis include:
- Allergic
- One of the most common causes
- Often worsened because of pruritis or irritation and the patient rubs the eyes as well.
- Pterygium – extension of the conjunctival tissues over the cornea which appears opaque. Usually seen in older patients because of environmental irritation such as UV light, it can be seen in pediatric patients with chronic allergies.
- Infectious
- Viral
- Bacterial including Neisseria gonorrhea
- Conjunctivitis – has edema of the conjunctival tissues with blood vessel engorgement and pain. Can be difficult to differentiate from allergic or bacterial causes.
- Cellulitis secondary to infected insect bite or minor abrasions is common.
- Trauma
- Directly to the ophthalmological structures but also to surrounding structures
- Neurosurgical and odontogenic surgical procedures can also cause chemosis. Consider non-accidental trauma as well
- Chemical conjunctivitis
- Corneal abrasion or foreign body
- Contact lens overuse
- Blepharocele – cerebrospinal fluid leaking into the eyelid
- Systemic
- Infiltrative such as leukemia
- Congenital chemosis
Questions for Further Discussion
1. What factors do you consider for treatment with antibiotics when you see conjunctivitis?
2. In neonates or young infants with eye drainage, what factors do you consider for potential antibiotic treatment?
3. Although eyes are protected sites, how does cancer present in the eye tissues?
Related Cases
- Disease: Chemosis | Eye Diseases | Eye Infections
- Symptom/Presentation: Red Eyes
- Specialty: Ophthalmology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Pink Eye
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Gandhi A, Das S. Conjunctival chemosis or not? Indian J Ophthalmol. 2018;66(10):1394. doi:10.4103/ijo.IJO_456_18
Narang S, Mehta A, Latawa A, Dogra M. Atypical chemosis: eyelid blepharocele. BMJ Case Rep. 2020;13(8):e237826. doi:10.1136/bcr-2020-237826
Azari AA, Arabi A. Conjunctivitis: A Systematic Review. J Ophthalmic Vis Res. 2020;15(3):372-395. doi:10.18502/jovr.v15i3.7456
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa