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Diagnostic Puzzler: Acute Eyelid Edema

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Diagnostic Puzzler: Acute Eyelid Edema OnlIne ExcLuSive Omar Rayward, MD, Diagnostic puzzler: PhD; Jose Luis Vallejo-Garcia, MD; Paula Moreno-Martin, Acute eyelid edema MD; Sergio Vano-Galvan, MD, PhD Hospital Clinico San Carlos, Madrid, Spain The patient’s eyelid was not inflamed or painful, but it (Dr. Rayward); Humanitas Clinical and Research was swollen enough to impair his vision. What’s your Center, Milan, Italy diagnosis? (Dr. Vallejo-Garcia); Hospital del Henares, Coslada, Madrid (Dr. Moreno-Martin); Hospital Ramón y Cajal, Madrid (Dr. Vano-Galvan) 68-year-old man sought care in our mation (FiGuRE). The patient also had right emergency department for unilateral supraciliary folliculitis that was improving; the [email protected] ptosis following superior and inferior folliculitis had been treated 3 days earlier at a The authors reported no A potential conflict of interest right eyelid edema. The patient said that the primary care facility. relevant to this article. edema had developed 3 days earlier and was We performed a complete ocular exami- getting worse each day; the ptosis was impair- nation, including visual acuity (20/20 in both ing his vision. The patient indicated that the eyes) and found no other significant prob- edema was accompanied by mild burning in lems. Nor did the patient have a fever or any the right periocular region. His medical his- other systemic symptoms. tory included arterial hypertension, which was under control, and bilateral cataract surgery 5 years ago. ● What is Your diAgnosis? On examination, we noted superior and inferior nontender painless eyelid edema on ● HoW Would You Treat This the right eye, with no signs of acute inflam- patienT? FiGuRE Edema of the upper and lower eyelid PHO T o COUR T ES Y OF : o m A r Raywa rd, MD The swelling was not accompanied by inflammation or fever, but it did impair the patient’s vision. jfponline.com Vol 62, no 5 | mAY 2013 | The journAl of FamilY prAcTice E1 Diagnosis: If you suspect orbital cellulitis, order an Noninflammatory eyelid edema orbital computed tomography scan with con- The fact that the patient’s eyelid was edema- trast infusion, including axial and coronal tous (but not tender or red) and that he’d views; it may reveal an infection of the soft been scratching the area following a case of tissue behind the orbital septum. Treat this folliculitis prompted us to diagnose nonin- condition with broad-spectrum intravenous flammatory eyelid edema. antibiotics (ceftriaxone) for 1 week, followed Noninflammatory eyelid edema—also by 2 weeks of oral antibiotics, completing a called noninflammatory palpebral edema— total of 21 days of antibiotics. is a relatively common disorder that usually z Hordeolum is a localized infection that occurs after some local irritation or micro- occurs when a meibomian gland becomes trauma. In its early phase, patients start out blocked. It usually appears as a palpable sub- with nonerythematous, painless edema of cutaneous nodule within the eyelid and re- the upper eyelid, which eventually affects the quires treatment with warm compresses and lower eyelid. a combination of antibiotics and steroid topi- As was the case with our patient, this dis- cal ointment (tobramycin and dexametha- order is not associated with fever or any other sone ophthalmic ointment 4 times a day for systemic sign or symptom. Complete blood a week).4 count and C-reactive protein will be nega- z Acute dacryoadenitis is a lacrimal Noninflammatory tive, as no infection or systemic alteration is gland infection that usually causes unilateral, eyelid edema present. painful swelling of the outer third of the upper is a relatively lid. You may also see tearing and discharge.5 common consider these infectious alternatives Look for an elevated WBC count; however, disorder that In cases like this one, be sure to differentiate blood cultures are rarely positive. These pa- usually appears between noninflammatory palpebral edema tients must be referred to an ophthalmolo- after some and other common but less benign ocular gist as treatment varies from symptomatic local irritation conditions. Among the infectious causes of measures in viral cases (warm compresses or microtrauma. unilateral edema to rule out: and a nonsteroidal anti-inflammatory drug, z Preseptal cellulitis is an infection that such as ibuprofen) to hospitalization and oral is localized between the skin and the orbital or intravenous antibiotics (eg, amoxicillin/ septum. This disorder usually appears as a clavulanate for at least 7 days), depending on tender erythematous eyelid edema with no the severity and origin of the infection.6 proptosis and no pain with eye movement.1 It is usually accompanied by an elevated white Ruling out other noninfectious disorders blood cell (WBC) count. Blood cultures are Noninfectious inflammatory diseases should rarely positive, but when they are, Haemophi- also be part of the differential diagnosis, lus influenzae is the most frequent pathogen.2 including: Preseptal cellulitis is treated with broad- z idiopathic orbital inflammation. Also spectrum oral antibiotics (amoxicillin/ known as orbital pseudotumor, this disorder clavulanate) for at least 7 days. is a nongranulomatous acute-to-subacute z Orbital cellulitis is an infection that inflammatory disease with no systemic mani- affects the orbital extraocular structures. It festations.7 It frequently involves the lacrimal can lead to blindness, so prompt diagnosis is gland and can cause abrupt pain, conjunc- critical. tival edema, and lid edema. Other common Orbital cellulitis usually develops when signs are proptosis and ocular motility altera- a sinus infection spreads into the orbit.3 Sus- tions, which the patient may report as diplo- pect it in a patient with proptosis, orbital pia and visual impairment. pain, tenderness, conjunctival chemosis, de- This disorder can result from optic neu- creased vision, elevated intraocular pressure, ropathy, exudative retinal detachment, or and pain on eye movement. Also look for an uveitis. It is a diagnosis of exclusion and is of- elevated WBC count. Perform blood cultures ten arrived at by seeing the patient respond to confirm the presence of a pathogen. to systemic corticosteroids. The specific drug E2 The journAl of FamilY prAcTice | mAY 2013 | Vol 62, no 5 ACUTE EYELID EDEMA and dose will vary based on disease severity. intense itching a few hours after exposure to z Graves’ ophthalmopathy. This bilat- the allergen. A cosmetic product is often the eral, asymmetric immunological disorder culprit. As you might expect, initial treatment affects the conjunctiva, eyelids,8 extraocular calls for withdrawal of the offending product. muscles, lacrimal gland, and optic nerve. Al- Instruct the patient to apply a topical steroid though it is typically diagnosed clinically, thy- ointment on the eyelid if the edema is intense. roid hormone abnormalities (increased T4 and a drop in thyroid-stimulating hormone) Good news for our patient help support the diagnosis. In the acute Diagnosing noninflammatory eyelid ede- phase, it has to be treated with systemic ste- ma requires keen observational skills and a roids; if the condition becomes chronic, the knowledge of several alternative diagnoses. complications may require surgery. Treat- Fortunately for our patient, this benign con- ment of the underlying hyperthyroidism may, dition did not require any local or systemic in some cases, worsen the ophthalmopathy. treatment. The edema resolved on its own in z One more consideration. Finally, con- 6 days. JFP 9 sider a local allergic reaction in the eyelids, cORRESPONDENcE which can also cause painless palpebral ede- omar rayward, md, calle profesor martín lagos, madrid, ma. Expect to see erythematous edema and spain 28040; [email protected] The condition references does not require 1. Bilyk JR. Periocular infection. Curr Opin Ophthalmol. enitis. Optom Vis Sci. 2000;77:121-124. any local 2007;18:414-423. 6. Durand ML. Periocular infections. In: Mandell GL, Bennett JE, or systemic 2. Jackson K, Baker SR. Periorbital cellulitis. Head Neck Surg. 1987; Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and 9:227-234. Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier treatment. 3. Adam R, Gupta V, Harvey J. Question: can you identify this con- Churchill Livingstone; 2009:1569-1575. dition? This condition is orbital cellulitis. Can Fam Physician. 7. Cooney NL. Orbital pseudotumor. Int J Emerg Med. 2009;2:263. 2009;55:1097. 8. Imaizumi M. Recurrent upper eyelid edema as first sign of 4. Lindsley K, Nichols JJ, Dickersin K. Interventions for acute inter- Graves’ disease. Thyroid. 2006;16:95-96. nal hordeolum. Cochrane Database Syst Rev. 2010;(9):CD007742. 9. Friedlaender MH. Objective measurement of allergic reactions in 5. Colegrove JA. Localized orbital inflammation: a case of dacryoad- the eye. Curr Opin Allergy Clin Immunol. 2004;4:447-453. jfponline.com Vol 62, no 5 | mAY 2013 | The journAl of FamilY prAcTice E3.
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