Review of Symptoms, Part VII

What Lies Beneath Lid Swelling

A variety of conditions ranging from mild to life-threatening can result in swollen eyelids. Here’s how you can determine what’s causing your patient’s problem.

Oftentimes, the patient’s appearance and presenting signs and symptoms will guide your diagnosis. In this seventh installment of our series “Review of Symptoms,” we review those disorders that present with focal or diffuse lid swelling. 

Infections
The most common etiology of lid swelling involves an infection of the lid tissue or its associated sebaceous and sweat glands. Some specific conditions you might encounter include:

• Hordeolum. This term refers to an acute infection of the glands within the lid. Patients with hordeola manifest a focal, elevated, tender nodule within or on the surface of the lid. The most notable symptom is pain, particularly on manipulation or attempted lid eversion. Also, the area is usually red and warm to the touch.


Hordeola fall into two groups: internal, which affect the meibomian glands, and external, which affect the glands of Zeiss and Moll. Internal hordeola present as an erythematous cyst within the lid. You can see these from both the dermal and conjunctival surfaces. External hordeola may demonstrate an area of drainage on the lid surface. 
 

• Cellulitis. Infections of the glands may be localized and self-limiting, or they may spread to adjacent glands or surrounding lid tissue. This creates a preseptal cellulitis, which also may follow penetrating trauma. 


As the name implies, preseptal cellulitis involves all the tissues of the lid anterior to the septum orbitale. Presenting signs and symptoms include acute pain and pronounced, diffuse lid edema, often to the point that patients cannot voluntarily open the involved eye. 

You must differentiate preseptal cellulitis from the more severe orbital cellulitis. The latter may cause significant morbidity and even mortality. Both conditions present with an acutely painful, swollen lid, but many distinguishing features help to differentiate them (see “Differential Diagnosis: Preseptal vs. Orbital Cellulitis,” below). 

Orbital cellulitis involves a bacterial infection of the lid tissues both anterior and posterior to the septum orbitale. This condition may result from a sinus infection or dental abscess. The infection can spread through a valveless venous system, leading to cavernous sinus thrombosis, meningitis, intracranial infection and septicemia. (Cavernous sinus thrombosis itself may contribute to eyelid edema, usually bilaterally. Proptosis and chemosis usually characterize this.) 

Additional ocular and systemic side effects of orbital cellulitis may include central retinal artery occlusion, optic neuritis and atrophy, abscess of the orbit and brain abscess. 

Systemic antibiotics are necessary to properly manage both preseptal cellulitis and orbital cellu- litis. However, patients with orbital cellulitis should be hospitalized immediately for a course of parenteral antibiosis.
 

Herpes simplex virus (HSV). This well-known corneal pathogen often manifests initially as an acute blepharitis or blepharoconjunctivitis. This is especially common in children, but may also occur in adults. 

HSV blepharoconjunctivitis typically presents in one of two forms: the classic appearance involves an accumulation of small, pinhead-sized vesicles with an inflamed, erythematous base along the lid margin or periocular skin (these vesicles ulcerate and harden into crusts within a week of the initial presentation); and the “erosive-ulcerative” variety, characterized by one or more large erosions (3-5mm) of the lid surface at or near the Gray line, and smaller ulcers (1-3mm) along the lid margin. A swollen pre-auricular node on the involved side is common. 

You’ll need to consider impetigo as a differential diagnosis. 

• Infection of the lacrimal system. This, too, may result in significant lid swelling. There are two forms of infection to consider: dacryocystitis and dacryoadenitis.

Dacryocystitis, an acute bacterial infection of the lacrimal sac, presents with focal erythematous swelling and edema overlying the nasal aspect of the lower lid. The upper lid may also show variable edema. This type of infection most often occurs in older patients and those with poor hygiene. In rare instances, dacryocystitis occurs due to lacrimal sac tumors; consider this diagnosis especially if there’s associated bleeding from the puncta.

Patients with dacryocystitis report significant pain, especially upon palpation, and often manifest a fever. Mucopurulent discharge may be evident in the cul-de-sac; you can express this through the punctum by digitally applying pressure to the lacrimal sac. Keep manipulation to a minimum to avoid disseminating the infection. Dilation and irrigation of the canaliculi is absolutely contraindicated. 

Dacryoadenitis is an inflammation of the primary lacrimal gland. Acute dacryoadenitis is typically infectious in nature, and presents unilaterally with pain, ocular redness, tearing and swelling of the upper lid. This condition presents with inflammation of the outer one-third of the upper eyelid in a characteristic but peculiar S-shaped swelling. 

This type of swelling typically involves only the palpebral lobe of the lacrimal gland. If the orbital lobe is also affected, you may observe inferonasal globe displacement, proptosis and impairment of ocular motility. Other signs of dacryoadenitis include preauricular lymphadenopathy, fever, conjunctival chemosis and an elevated white blood cell count. Children and young adults are the most common age group to be affected.

• Contact dermatitis. Usually, the patient has a history of using a new substance, such as a cosmetic, detergent, contact lens solution or ocular medication. Lid swelling in contact dermatitis can be variable, but usually there is at least moderate edema within the tissues. Erythema may be less pronounced than in infectious lid disorders, and pain is rare. 

 
• Insect and arachnid  bites and stings. The venom associated with the stings of insects (bees, wasps and hornets) and spider bites produces an acute anaphylactic reaction. The trauma need not involve the lid directly, but is most pronounced when the bite or sting occurs near the eyes. Acute allergic reactions may also follow insect bites (ants, fleas, mites and ticks), as can secondary infections, leading to preseptal cellulitis. 


Other small flying insects, such as mosquitoes and gnats, may inadvertently enter the eye. The highly toxic proteins within these organisms produce a profound reaction that includes intense itching, lid swelling and conjunctival chemosis. There is no involvement of the preauricular lymph nodes. 

Intense itching, both on the epidermal surface of the eyelid and within the conjunctival tissues, is the hallmark symptom of all allergic ocular conditions. Other associated findings may include burning, tearing and redness of the bulbar conjunctiva. In a true toxic reaction there will not be a preauricular lymphadenopathy.

All forms of toxic lid reactions are self-limiting, but respond well to cold compresses, antihistamines (both topical and oral) and topical corticosteroids.

Inflammatory/Infiltrative disease
Non-infectious inflammation and infiltration can also induce lid swelling. Such conditions include:

• Chalazion. This is one of the more common focal inflammatory conditions of the eyelid. A chalazion is a non-infectious, encapsulated granuloma that usually involves the meibomian or Zeiss glands. The history may involve a hordeolum that resolved with a residual “lump” (secondary chalazion), or the chalazion may arise de novo. 


Chalazia result from chronic blockage of the secretory ducts of these glands; secretory material then accumulates and eventually hardens into a nodule. These lesions range from mildly firm to hard and nodular. 

Unlike hordeola or other lid infections, chalazia have no associated pain or tenderness. Patients usually only report a mild awareness of the lesion, and often seek treatment because they don’t like the appearance.

• Systemic conditions. Generalized eyelid inflammation and infiltration may occur with many systemic disorders, especially sarcoidosis and thyroid disease. Lid swelling usually results from lacrimal gland infiltration (chronic dacryoadenitis) or the development of sarcoid nodules within the skin of the lids. 

Thyroid eye disease, or Graves’ disease, occurs in up to 80% of patients with systemic hyperthyroidism, but may also occur in some patients with normal thyroid function. Periorbital edema, which results in lid swelling, is one of the earliest signs of thyroid eye disease. Other associated findings include conjunctival edema and infiltration of the lacrimal gland, both of which contribute to this swelling. As the condition progresses and infiltrates the extraocular muscles and orbital tissue, proptosis and a characteristic “stare” result. This is typically bilateral, but asymmetric presentations also may occur. 

Infiltration of the orbit and/or lacrimal gland with subsequent swelling of the lids may also occur in neoplastic disorders, most notably leukemia, lymphoma and metastatic disease. 

• Rosacea. This idiopathic dermatologic condition involves the sebaceous glands of the face and neck. This disorder alters the consistency of the sebum, resulting in glandular hypertrophy, erythema, telangiectasias, acneform papules and pustules of the affected skin. You can encounter significant ocular pathology since the meibomian glands are modified sebaceous glands.


Ocular rosacea typically presents with a chronic, unrelenting blepharitis with thickened, erythematous lid margins and inspissated glands. Lid swelling and blepharoptosis is common. 
 

• Pyogenic granuloma. This small, rounded mass of highly vascular tissue often occurs secondary to trauma or surgery.

Keep in mind that some non-inflammatory conditions, specifically angioedema and cardiac or renal disease, may also cause lid swelling. Also, elderly patients may have a benign prolapse of orbital fat.

The supraorbital ridge limits most traumatic lid swelling superiorly, and the malar and nasojugal folds do the same inferiorly. However, blood and other fluids can extravasate across the loose skin in the ethmoid region, resulting in swelling and ecchymosis of the contralateral eyelid in some instances. 

The history is the definitive finding in most cases of traumatic lid swelling. However, clinical entities such as orbital fracture may present with severe lid swelling days later, and present a diagnostic challenge. Blow-out fractures of the ethmoid wall can create a communication between the sinus and the orbit. Patients who vigorously blow their nose may force air into the orbit (orbital emphysema) and present with actual inflation of the eyelids on the involved side. You can diagnose this by palpating the lids for crepitus; gentle but firm manipulation of the tissue results in a “popping” or “crackling” sound as trapped air escapes. 

All cases of blunt ocular trauma warrant imaging. Computed tomography (CT) scanning is the preferred modality because it reveals bony defects. (For a more complete discussion, see the 2-part Optometric Study Center series, “Adding Insight to Injury,” March 2000, and “How to Manage Fractures and Penetrations,” April 2000.)

Eyelid swelling is often disconcerting for patients, and may have a vast number of etiologic factors. A probing history and evaluation, and careful consideration of the associated signs and symptoms will allow you to properly diagnose and manage these patients.

Drs. Sowka and Kabat are on the faculty at Nova Southeastern University College of Optometry, Fort Lauderdale, Fla.

top
 

Differential Diagnosis: Preseptal vs. Orbital Cellulitis Sign/Symptom Preseptal Cellulitis Orbital Cellulitis Lid edema (swelling) Lid erythema (redness) Pain History of trauma or               infection Proptosis Reduced Vision Reduced motility/diplopia Fever Afferent pupillary defect Yes Yes Yes Yes No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Possible top

 
Return to September 2000 Highlights

© Review of Optometry OnLine
September 15, 2000