What causes peri-orbital (around the eye) puffiness?

Causes of Periorbital Puffiness

Periorbital puffiness is most commonly caused by fluid retention in the eyelid tissues, thyroid eye disease, allergic reactions, infections, or underlying systemic conditions that affect fluid balance in the body.

Common Causes of Periorbital Puffiness

Inflammatory/Allergic Causes

• Allergic reactions
  • Contact dermatitis (44% of periorbital dermatitis cases) 1
  • Airborne allergens (10% of cases) 1
  • Allergic conjunctivitis 1
  • Atopic eczema (25% of cases) 1

Infectious Causes

• Orbital/Periorbital infections
  • Preseptal cellulitis - infection confined to eyelids and tissues anterior to orbital septum 2
  • Postseptal cellulitis - usually secondary to sinusitis (particularly ethmoid) 2
  • Orbital abscess 2
• Sinusitis
  • Ethmoid sinusitis commonly spreads to orbit through the thin lamina papyracea 2

Endocrine Causes

• Thyroid eye disease

  • Associated with hyperthyroidism (most often Graves' disease)
  • Can also occur with normal-functioning or under-functioning thyroid 2
  • Presents with bilateral but potentially asymmetric edema and erythema of periorbital tissues 2
  • Risk factors include family history of thyroid disorders and cigarette smoking 2

• Hypothyroidism

  • Long-standing cases develop characteristic edematous skin changes called myxedema 3

Vascular/Fluid Balance Causes

• Fluid retention
  • Morning puffiness due to overnight fluid accumulation
  • Increased salt intake
  • Decreased lymphatic drainage
  • Microvasculature congestion and permeability issues 4

Neoplastic Causes

• Orbital tumors
  • Can present with unilateral proptosis and periorbital swelling 2
  • May include neoplasms like plexiform neurofibromas in NF1 patients 2

Trauma/Iatrogenic Causes

• Post-surgical edema 5
• Trauma to periorbital tissues 5
• Medication-related
  • Thiazolidinediones (TZDs) can cause peripheral edema including periorbital region 3

Clinical Evaluation Algorithm

1. Determine if unilateral or bilateral

   • Unilateral: More concerning for infection, tumor, or trauma
   • Bilateral: More likely systemic, allergic, or fluid-related

2. Check for red flag symptoms

   • Proptosis
   • Restricted ocular movements
   • Visual changes or relative afferent pupillary defect
   • Fever (>100.4°F/38°C)
   • These suggest orbital cellulitis requiring urgent evaluation 6

3. Evaluate for associated symptoms

   • Itching (suggests allergic etiology)
   • Pain (suggests infection or inflammation)
   • Discharge (suggests infection)
   • Systemic symptoms (fever, weight changes, fatigue)

4. Consider timing and pattern

   • Morning puffiness that improves during day (suggests fluid retention)
   • Persistent or worsening puffiness (suggests underlying pathology)
   • Recurrent episodes (suggests allergic or chronic condition)

Diagnostic Approach

Physical Examination

• Assess for proptosis, orbital asymmetry
• Check extraocular movements
• Evaluate for visual acuity changes
• Look for signs of inflammation (redness, warmth)
• Palpate for firmness, nodularity, or "bag of worms" texture (suggestive of plexiform neurofibroma) 2

Imaging

• CT orbits with contrast: First-line for suspected infection or trauma 2
• MRI orbits: Better for soft tissue characterization when mass lesion is suspected 2
• MRI brain and orbits: For suspected intracranial extension or to evaluate extent of disease 2

Special Considerations

Pediatric Patients

• Children presenting with periorbital asymmetry or unilateral proptosis should be evaluated for orbital plexiform neurofibromas, especially if NF1 is suspected 2
• Unilateral periorbital swelling in children needs thorough evaluation to differentiate between preseptal and orbital cellulitis 6

Thyroid Eye Disease

• Bilateral but potentially asymmetric
• Associated findings: upper eyelid retraction, exposure keratopathy, extraocular muscle enlargement, proptosis, compressive optic neuropathy 2
• Risk factors: cigarette smoking, family history of thyroid disorders 2

Common Pitfalls to Avoid

1. Misdiagnosing orbital cellulitis as preseptal cellulitis

   • Can lead to vision-threatening or life-threatening complications 6
   • Always evaluate for proptosis, ocular movement restrictions, and visual changes

2. Failing to consider systemic causes

   • Periorbital puffiness may be the presenting sign of thyroid disease or other systemic conditions

3. Overlooking sinusitis as a cause

   • Ethmoid sinusitis commonly spreads to orbit through the thin lamina papyracea 2

4. Delaying imaging in concerning cases

   • When red flags are present, prompt imaging is essential to rule out serious pathology

By systematically evaluating the pattern, associated symptoms, and risk factors of periorbital puffiness, clinicians can effectively identify the underlying cause and initiate appropriate management to prevent complications.