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Eyelid Swelling

By

Christopher J. Brady

, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine

Last full review/revision May 2021| Content last modified May 2021
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Eyelid swelling can be unilateral or bilateral. It may be asymptomatic or accompanied by itching or pain.

Etiology of Eyelid Swelling

Eyelid swelling has many causes (see table Some Causes of Eyelid Swelling Some Causes of Eyelid Swelling Eyelid swelling can be unilateral or bilateral. It may be asymptomatic or accompanied by itching or pain. Eyelid swelling has many causes (see table Some Causes of Eyelid Swelling). It usually... read more ). 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

Table
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Evaluation of Eyelid Swelling

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.

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 angiotensin-converting enzyme (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 or both eyelids of one eye or one or both eyelids in 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 Edema Edema is swelling of soft tissues due to increased interstitial fluid. The fluid is predominantly water, but protein and cell-rich fluid can accumulate if there is infection or lymphatic obstruction... read more Edema , which suggests a systemic cause. If a systemic cause is suspected, see the topic Edema Edema Edema is swelling of soft tissues due to increased interstitial fluid. The fluid is predominantly water, but protein and cell-rich fluid can accumulate if there is infection or lymphatic obstruction... read more Edema 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.

Testing

In most cases, diagnosis can be established clinically and no testing is necessary. If orbital cellulitis Preseptal and Orbital Cellulitis Preseptal cellulitis (periorbital cellulitis) is infection of the eyelid and surrounding skin anterior to the orbital septum. Orbital cellulitis is infection of the orbital tissues posterior... read more Preseptal and Orbital Cellulitis or cavernous sinus thrombosis Cavernous Sinus Thrombosis Cavernous sinus thrombosis is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by nasal furuncles or bacterial sinusitis. Symptoms and signs include pain, proptosis... read more 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 of Eyelid Swelling

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

Key Points

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When treating a patient with a foreign body in the eye, examination of the eye using a slit lamp is appropriate. If at any time during the examination an intraocular foreign body or penetrating injury is suspected, which of the following is the most appropriate next step?
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