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A 49-year-old man with unilateral, nontender left eyelid swelling
Digital Journal of Ophthalmology 2014
Volume 20, Number 1
January 17, 2014
DOI: 10.5693/djo.03.2013.09.007
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Brandon J. Wong, BA | Keck School of Medicine, University of Southern California, Los Angeles, California
Bryan K. Hong, MD | Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
Daman Samrao, MD | Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California
Gene H. Kim, MD | Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California
Narsing A. Rao, MD | Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
Differential Diagnosis
Because of the nonspecific appearance of the eyelid edema, the initial differential diagnosis was very broad, encompassing infection, thyroid orbitopathy, blepharochalasis, angioedema, lymphedema, allergic or contact dermatitis, eyelid malignancy, periorbital pseudotumor, ocular rosacea, and eosinophilic granuloma.

Eyelid infections, such as periorbital or orbital cellulitis, may present with eyelid edema. Periorbital infections are preseptal and can be caused by trauma, bacteremia, or upper respiratory illnesses. Patients experience eyelid induration, erythema, and tenderness. Orbital cellulitis involves the orbit itself; symptoms are severe, including proptosis, pain on eye movement, ophthalmoplegia with diplopia, and decreased visual acuity. A diagnosis of periorbital or orbital cellulitis can be made based on history and physical examination, although computed tomography or magnetic resonance imaging can be helpful in evaluating for orbital cellulitis and its complications.

Thyroid orbitopathy can cause chronic eyelid edema, although it is usually bilateral and occurs in older individuals (40-60 years of age). It is associated with lagophthalmos, eyelid retraction, and proptosis. It can be excluded by laboratory tests and orbital imaging studies.

Blepharochalasis can also present with eyelid edema that is usually bilateral, although it can occur unilaterally. It is characterized by recurrent episodes of nonpainful, nonerythematous upper eyelid swelling that usually begins in childhood or adolescence. These episodes last an average of 2 days, but recurrent episodes can cause the eyelids to become discolored, thin, and wrinkled, with the classic appearance of tissue paper. These episodes have been noted to decrease in frequency as patients age. Treatment is primary surgical and aims to restore function and maintain cosmesis.(1)

Angioedema can be hereditary or acquired. Hereditary angioedema can be detected with laboratory testing for C1 inhibitor protein and complement C4 levels. The acquired form is often caused by an immunologic response to an allergen and may occur with other allergy symptoms. Angioedema due to an allergen usually responds to treatment with antihistamines or steroids.

Lymphedema is usually the result of invasive surgical procedures that result in lymphoceles or lymph fistulas, which are most commonly described in vascular procedures involving the lower extremities. Lymphorrhea is usually a clear, amber-colored fluid unlike the dark fluid seen in our patient.

Allergic or contact dermatitis could also present with eyelid swelling. This hypersensitivity reaction can occur with a variety of allergens, and patients present with pruritus and inflammation at the affected site. A unilateral presentation would be uncommon, and our patient did not identify any unusual contacts to precipitate an allergic response. Diagnosis can be made clinically, with an emphasis on a detailed history, and is confirmed by patch testing.

Eyelid malignancies, periorbital pseudotumor, and eosinophilic granulomas may be diagnosed by biopsy. Patients with ocular rosacea may present with associated skin findings, including rhinophyma, pustules, papules, and erythema.
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