Eyelid edema

Etiology

• Eyelid edema is the result of a fluid shift into the soft tissue of the eyelid structures with subsequent swelling; this can occur from a variety of etiologic factors.
• Infectious
• Inflammatory
• Neoplasm related
• Medication related
• Trauma/ Postsurgical/post injection
• Metabolic
• Generalized senescence of the lymphatic networ as a consequence of aging
• Others

Epidemiology

• This is a sporadic event which could be idiopathic or related to the underlying disease
• Can occur at any age, and no sex predilection
• Depending on the causative factor a single eyelid,  unilateral, bilateral or all four eyelids could be affected

History

• Acute or chronic
• Unilateral/bilateral, upper eyelids/lower eyelids, single eyelid
• Number of episodes (first time or recurrent), age at onset
• Determine how long it is present (is it present all day long, worse in the morning, etc)
• Presence of itching or pain
• Any recent trauma
  • previous surgeries
  • traumas
  • insect bites
• Medicine used:
  • Orally or parentally not around orbit ( list of drugs reported to produce edema, Table 1)
  • Recent periorbital injections or within last few years¹.
• Recent contact with skin care products
• Any other reason for contact dermatitis (detergent, etc)
•  Systemic symptoms of swelling, collagen vascular disease

Table 1: Systemic medications with a history of inducing ocular adnexal edema

Pertinent clinical features

• External examination should be done in 3 steps: eyelids and orbit, periorbital region including face and rest of the body.
• Eyelids and Orbit
• Eyelids
• Swelling
• Color change
• erythematous
• violaceous
• yellowish or xanthomatous Fig. 1
• Skin texture
• Cigarette paper like skin associated with blepharochalasis. Recurrent swelling bilaterally. Extremely rare unilateral ²¹. Fig 2.
• Lichenification is frequently seen in atopic dermatitis, eyelids are affected in about 15% of cases ²² Fig. 3.
• Signs of local local trauma, or insect bite ²³
• Edema with vesicles is associated with herpes simplex. Vesicles can appear later in course ²⁴.
• Orbit
• Evidence of mass effect, orbital inflammation, motor or sensory nerve involvement.
• Conjunctiva
• Chemosis.
• Salmon patch, lacrimal gland enlargement or other mass
• Pain on touch or with globe movement.

Fig.1. Yellowish discoloration of the skin in orbital xanthogranuloma

Fig 2. Cigarette paper like skin in blepharochalasis

Fig 3. Eczema and lichenification in atopic dermatitis

• Face
  • Rosacea dermatitis, suggested by malar flushing, rhinophyma (Fig. 5)
  •  Periorbital dermatitis or vasculitis (dermatomyositis, lupus, Smarts, etc) ²⁵
  • Angioedema. Predominantly eyelids, lips and upper airways are involved. Could be acute or chronic. If acute try to avoid a causative agent. List of drugs used should be evaluated. ACE are responsible for more than 30% of cases. Ask for episodes of abdominal pain, about 93% of patients with hereditary angioedema experience recurrent abdominal pain ²⁶. If chronic look for dietary and drug history. Screen for C1 inhibitor deficiency. Bare in mind that there is a so called type III hereditary angioedema with normal C1inhibitor with the female predominance ²⁷
  • Paralysis, fissured tongue, facial swelling suggesting Melkerson_Rosenthal syndrome ²⁸.  Fig. 4.
  • Eyebrow and cheek fat enlargement associated with thyroid-associated orbitopathy ²⁹
• Body. Look for signs of edema. Hepatic, cardiac, renal disease, hypothyroid state, low protein state are among the disorders that cause generalized edema. A hallmark of  systemic edema is exacerbation of the swelling in the morning followed by gradual improvement during the day.
• Superior vena cava syndrome (SVCS). Early in clinical course may be asymptomatic. Look for minor signs. Dyspnea 63%, head fullness, cough, arm swelling, chest pain. Check for malignant mediastinal tumors, these represent more than 80% of SVCS ³⁰.
• Nephrotic syndrome may be associated with lower extremity and eyelid edema ³¹.
• Eyelid swelling can be the first sign of Thyroid Eye Disease; Graves thyroid disease with goiter and hyperthyroid symptoms may be present.
• The musculoskeletal system should be evaluated in case of suspected dermatomyositis. Edema with violaceous color change. Skin changes such as heliotrope, gottron papules may be found. Proximal muscle weakness, arthralgia ³².

Fig.4  Melkerson-Rosenthal syndrome

Fig. 5  Rosacea and eyelid edema

Establishing the diagnosis

• Laboratory Testing: Lab tests should be based on the suspected etiologic factors. Infectious, autoimmune, renal, cardiovascular systems should evaluated. Thyroid function, CBC with differential, erythrocyte sedimentation rate, C-reactive protein, ANCA, angiotensin-converting enzyme, antinuclear antibody, lysozyme, syphilis serologies, purified protein derivative test

• Imaging:  CT or MR imaging is appropriate if orbitofacial or cranial lesion is suspected as a causative factor.

• Biopsy should be solicited in case if systemic work out and imaging are inconclusive to establish the diagnosis ³³.

• Autoimmune disease (Graves, lupus, sarcoid, vasculitis, etc)
• Atopy
• Periorbital surgery/trauma/injections
• Systemic edema
• Travel to endemic region for parasites.
• Trauma of craniofacial region cause eyelid swelling in up to 97 % of cases.
• Contact with animals (cutaneous anthrax) ³⁴.
• Periorbital surgery
• Drugs

• Allergy is one the most frequents causes of eyelid edema. A number of drugs have been associated with edema (Table 1.) The differential for conditions that cause edema is actually quite long. (Table 2.)

• The key is a definitive diagnosis and subsequent treatment of the causative factor.
• Allergic reaction should be managed by revealing the inciting agent. Most of the time a thorough history is the key. Antihistamines and corticosteroids may be appropriate.
• Systemic disease should be treated in conjunction with the specialist in the field.
• Post-surgical edema occurs after all surgeries. Infection, toxoallergic blepharoconjunctivitis, and rarely primary acquired cold urticaria, as well as lymphatic drainage disruption can be precipitating factors ⁸⁷. Preoperative list of allergies to medications should be thoroughly taken. Minimal anatomical manipulation of lateral periorbita should be considered in order to prevent the disruption of the lymphatic drainage. Four eyelid blapharoplasty may have higher risk of prolonged post op edema if the lateral incisions are too close to each other, less than 2 mm ⁸⁸.
• In the absence of a specific diagnosis, nonspecific treatment can include salt avoidance, sleeping with the head of the bed elevated, diuretics, and rarely corticosteroids.

• Surgical intervention or any other inflammation mediators could worsen the edema.

• Sleep with head elevated for fluid retention
• Avoid known allergens, or precipitating medications
• Have the list of all known allergies and inform the physician prior any treatment.
• Contact physician if worsening

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• Additional Resources
• AAO, Basic and Clinical Science Course. Section 7. Orbit, Eyelids & Lacrimal system, 2014.
• Eyelid edema. Sami, MS, Soparkar CNS, Patrinely JR, Tower RN. Semin Plast Surg. 2007 February; 21(1): 24–31.
• Differential Diagnosis of the Swollen Red Eyelid ART PAPIER, MD; DAVID J. TUTTLE, MD; and TARA J. MAHAR, MD Am Fam Physician. 2007 Dec 15;76(12):1815-1824.
• Periorbital edema: a puzzle no more? Rachel K. Sobela, Keith D. Carter, and Richard C. Allen. Curr Opin Ophthalmol. 2012 Sep;23(5):405-14.