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). 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 the table 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 that cause swelling that begins and is usually most severe in structures near, but not part of, the eyelids (eg, dacryocystitis, canaliculitis)
Disorders in which swelling occurs but is not the presenting symptom (eg, basilar skull fracture, burns, trauma, postsurgery)
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 | History and physical examination |
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 | History and physical examination | |
Focal redness and pain involving only one eyelid Eventual development of localized, nonpainful swelling away from eyelid margin | History and physical examination | |
Conjunctivitis, infectious | Conjunctival injection, discharge Sometimes preauricular node, chemosis, or both Unilateral or bilateral | |
Herpes simplex blepharitis (primary) | Clusters of vesicles on an erythematous base, ulceration, severe pain Unilateral | History and physical examination |
Herpes zoster (shingles) | Clusters of vesicles on an erythematous base, ulceration, severe pain Unilateral, V1nerve root distribution | History and physical examination, including ophthalmic examination if eye involvement is suspected |
Focal redness and pain involving only one eyelid Eventual development of swelling localized to eyelid margin, sometimes with pustule | History and physical examination | |
Insect bite | Itching, redness, sometimes a papule | History and physical examination |
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 of brain and orbits |
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 of orbits | |
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 of orbits 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 | History and physical examination |
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 angiotensin-converting enzyme (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) |
Painless, bilateral diffuse facial puffiness Dry, scaly skin; coarse hair Cold intolerance | Thyroid function tests (TSH, T4) | |
* Swelling due to systemic disorders is bilateral and not erythematous. | ||
T4= thyroxine; TSH =thyroid-stimulating hormone; V1 = ophthalmic division of the trigeminal nerve. | ||
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.
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. Medication 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; whether it is present 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, which suggests a systemic cause. If a systemic cause is suspected, see the topic 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.
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 the table 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 of Eyelid Swelling
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.
