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Eyelid Swelling: A Merck Manual of Patient Symptoms podcast

Eyelid swelling can be unilateral or bilateral. It may be asymptomatic or accompanied by itching or pain.

Etiology

Eyelid swelling has many causes (see Table 7: Symptoms of Ophthalmologic Disorders: Some Causes of Eyelid Swelling). It usually results from an eyelid disorder but may result from disorders in and around the orbit or from systemic disorders that cause generalized edema.

The most common causes are allergic, including

• Local allergy (contact sensitivity)
• Systemic allergy (eg, angioedema, systemic allergy accompanying allergic rhinitis)

Focal swelling of one eyelid is most often caused by a chalazion.

The most immediately dangerous causes are orbital cellulitis and cavernous sinus thrombosis (rare).

In addition to the disorders listed in Table 7: Symptoms of Ophthalmologic Disorders: Some Causes of Eyelid Swelling, eyelid swelling may result from the following:

• Disorders that may involve the eyelid but do not cause swelling unless very advanced (eg, eyelid tumors, including squamous cell carcinomas and melanoma)
• Disorders (eg, dacryocystitis, canaliculitis) that cause swelling that begins and is usually most severe in structures near, but not part of, the eyelids
• Disorders in which swelling occurs but is not the presenting symptom (eg, basilar skull fracture, burns, trauma, postsurgery)

Table 7
Some Causes of Eyelid Swelling Cause Suggestive Findings Diagnostic Approach Eyelid disorders Allergic reaction, local Itching, no pain Pale, puffy eyelid or eyelids, conjunctiva, or both Sometimes history of recurrence, exposure to allergen, or both Unilateral or bilateral Clinical evaluation Blepharitis Lash involvement and crusting usually visible grossly or under magnification (eg, with slit lamp) Itching, burning, redness, ulceration, or a combination Sometimes concomitant seborrheic dermatitis Unilateral or bilateral Clinical evaluation Chalazion Focal redness and pain involving only one eyelid Eventual development of localized, nonpainful swelling away from eyelid margin Clinical evaluation Conjunctivitis, infectious Conjunctival injection, discharge Sometimes preauricular node, chemosis, or both Unilateral or bilateral Clinical evaluation, usually fluorescein staining to rule out herpes simplex keratoconjunctivitis Herpes simplex blepharitis (primary) Clusters of vesicles on an erythematous base, ulceration, severe pain Unilateral Clinical evaluation Herpes zoster (shingles) Clusters of vesicles on an erythematous base, ulceration, severe pain Unilateral, V1 nerve root distribution Clinical evaluation Hordeolum Focal redness and pain involving only one eyelid Eventual development of swelling localized to eyelid margin, sometimes with pustule Clinical evaluation Insect bite Itching, redness, sometimes a papule Clinical evaluation Disorders in and around the orbit Cavernous sinus thrombosis (rare) Headache, proptosis, ophthalmoplegia, ptosis, decreased visual acuity, fever Usually unilateral at first, then bilateral Manifestations of sinusitis or other facial infection Immediate CT or MRI Orbital cellulitis Proptosis, redness, fever, pain Impaired or painful extraocular movements Sometimes decreased visual acuity Usually unilateral Sometimes preceded by manifestations of the source infection (typically sinusitis) CT or MRI Preseptal cellulitis (periorbital cellulitis) Swelling (but not proptosis), redness, sometimes pain, fever Usually unilateral Vision and ocular motility normal Sometimes preceded by manifestations of the source infection (typically local skin infection) CT or MRI if necessary to exclude orbital cellulitis Systemic disorders* Allergic reaction, systemic (eg, angioedema, rhinitis) Itching Sometimes extraocular allergic manifestations (eg, urticaria, wheezing, rhinorrhea) Sometimes history of recurrence, exposure to allergen, atopy, or a combination Usually bilateral Clinical evaluation Generalized edema Bilateral asymptomatic eyelid and sometimes facial edema; usually also edema of dependent body parts (eg, feet, presacral region) Usually manifestations of underlying disorder (eg, chronic renal disease, heart failure, liver failure, preeclampsia) Sometimes use of an ACE inhibitor Testing for cardiac, hepatic, or renal disorders as clinically directed Hyperthyroidism (with Graves' ophthalmopathy) Stare, eyelid lag, proptosis, impaired extraocular movements Not painful unless cornea is irritated from drying Tachycardia, anxiety, weight loss Thyroid function tests (TSH, T4) Hypothyroidism Painless, bilateral diffuse facial puffiness Dry, scaly skin; coarse hair Cold intolerance Thyroid function tests (TSH, T4) *Swelling due to systemic disorders is bilateral not erythematous. T4 = thyroxine; TSH = thyroid-stimulating hormone; V1 = ophthalmic divsion of the trigeminal nerve.

Evaluation

History: History of present illness should ascertain how long swelling has been present, whether it is unilateral or bilateral, and whether it has been preceded by any trauma (including insect bites). Important accompanying symptoms to identify include itching, pain, headache, change in vision, fever, and eye discharge.

Review of systems should seek symptoms of possible causes, including runny nose, itching, rash, and wheezing (systemic allergic reaction); headache, nasal congestion, and purulent nasal discharge (sinusitis); toothache (dental infection); dyspnea, orthopnea, and paroxysmal nocturnal dyspnea (heart failure); cold intolerance and changes in skin texture (hypothyroidism); and heat intolerance, anxiety, and weight loss (hyperthyroidism).

Past medical history should include recent eye injury or surgery; known heart, liver, renal, or thyroid disease; and allergies and exposure to possible allergens. Drug history should specifically include use of ACE inhibitors.

Physical examination: Vital signs should be assessed for fever and tachycardia.

Eye inspection should assess the location and color of swelling (erythematous or pale), including whether it is present on one eyelid, both eyelids, or both eyes and whether it is tender, warm, or both. The examiner should observe whether the finding represents edema of the eyelids, protrusion of the globe (proptosis), or both. Eye examination should particularly note visual acuity and range of extraocular motion (full or limited). This examination can be difficult when swelling is marked but is important because deficits suggest an orbital or retro-orbital disorder rather than an eyelid disorder; an assistant may be required to hold the eyelids open. Conjunctivae are examined for injection and discharge. Any eyelid or eye lesions are evaluated using a slit lamp.

General examination should assess signs of toxicity, suggesting a serious infection, and signs of a causative disorder. Facial skin is inspected for dryness and scales (which may suggest hypothyroidism) and greasy scales or other signs of seborrheic dermatitis. Extremities and the presacral area are examined for edema, which suggests a systemic cause. If a systemic cause is suspected, see Symptoms of Cardiovascular Disorders: Evaluation for further discussion of the evaluation.

Red flags: The following findings are of particular concern:

• Fever
• Loss of visual acuity
• Impaired extraocular movements
• Proptosis

Interpretation of findings: Some findings help distinguish among categories of disorders. The first important distinction is between inflammation or infection and allergy or fluid overload. Pain, redness, warmth, and tenderness suggest inflammation or infection. Painless, pale swelling suggests angioedema. Itching suggests allergic reaction, and absence of itching suggests cardiac or renal dysfunction.

Swelling localized to one eyelid in the absence of other signs is rarely caused by a dangerous disorder. Massive swelling of the eyelids of one or both eyes should raise suspicion of a serious problem. Signs of inflammation, proptosis, loss of vision, and impaired extraocular movements suggest an orbital disorder (eg, orbital cellulitis, cavernous sinus thrombosis) that may be pushing the globe forward or affecting the nerves or muscles. Other suggestive and specific findings are listed in Table 7: Symptoms of Ophthalmologic Disorders: Some Causes of Eyelid Swelling.

Testing: In most cases, diagnosis can be established clinically and no testing is necessary. If orbital cellulitis or cavernous sinus thrombosis is suspected, diagnosis and treatment should proceed as rapidly as possible. Immediate imaging with CT or MRI should be done. If cardiac, liver, renal, or thyroid dysfunction is suspected, organ function is evaluated with laboratory tests and imaging as appropriate for that system.

Treatment

Treatment is directed at the underlying disorder. There is no specific treatment for the swelling.

Key Points

• Proptosis with impaired vision or extraocular movements suggests orbital cellulitis or cavernous sinus thrombosis, and diagnosis and treatment should proceed as rapidly as possible.
• Eyelid disorders should be differentiated from orbital and systemic causes of swelling.

Last full review/revision April 2009 by Kathryn Colby, MD, PhD

Content last modified April 2009