What are the causes and treatments of periorbital edema?

Causes of Periorbital Edema

Periorbital edema is commonly caused by endothelial dysfunction, elevated intraocular pressure, inflammation, allergic reactions, infections, or medication side effects, with treatment directed at the underlying cause.

Infectious Causes

• Preseptal/orbital cellulitis - bacterial infection of the eyelid tissues
• Sinusitis - particularly ethmoid sinusitis which can spread to orbital tissues
• Dacryocystitis - infection of the lacrimal sac
• Hordeolum (stye) or chalazion - localized infections of eyelid glands

Inflammatory/Immunologic Causes

• Allergic reactions - environmental allergens, food allergies, insect bites
• Contact dermatitis - cosmetics, eye drops, skin products
• Angioedema - hereditary or acquired
• Autoimmune conditions:
  • Lupus erythematosus (discoid and systemic forms) 1, 2
  • Dermatomyositis
  • Thyroid eye disease (Graves' ophthalmopathy)

Systemic Causes

• Fluid retention disorders:
  • Congestive heart failure
  • Nephrotic syndrome
  • Hypoproteinemia
• Endocrine disorders:
  • Hypothyroidism
  • Cushing's syndrome
• Vascular disorders:
  • Superior vena cava syndrome
  • Cavernous sinus thrombosis

Medication-Related Causes

• Drug reactions:
  • Imatinib (reported in up to 70% of treated patients) 3
  • Thyroid hormone replacement (rare delayed hypersensitivity) 4
  • NSAIDs
  • ACE inhibitors

Traumatic/Mechanical Causes

• Orbital trauma
• Post-surgical edema
• Crying/rubbing eyes

Neoplastic Causes

• Orbital tumors
• Metastatic disease
• Amyloidosis

Diagnostic Approach

When evaluating periorbital edema, consider:

1. Onset pattern:

   • Acute vs. gradual development
   • Unilateral vs. bilateral presentation
   • Diurnal variation (worse upon waking)

2. Associated symptoms:

   • Pain, redness, warmth (suggests infection)
   • Fever (suggests systemic infection) 5
   • Visual changes (suggests deeper orbital involvement)
   • Pruritus (suggests allergic etiology)

3. Imaging studies when needed:

   • Ultrasound biomicroscopy - particularly helpful in congenital and traumatic cases 3
   • Anterior segment OCT - can visualize deeper structures when edema is present

Treatment Approach

Treatment should target the underlying cause:

1. Infectious causes:

   • Topical or systemic antibiotics
   • When using bandage contact lenses, prophylactic broad-spectrum antibiotics should be considered 3

2. Inflammatory/allergic causes:

   • Topical or systemic corticosteroids
   • Antihistamines for allergic reactions
   • Immunosuppressants for autoimmune conditions

3. Medication-related edema:

   • Discontinuation or substitution of the offending medication
   • For imatinib-induced periorbital edema, diuretics have limited benefit 3

4. Systemic causes:

   • Treatment of the underlying condition (heart failure, kidney disease)
   • Sodium restriction and diuretics may help with fluid retention

5. Symptomatic management:

   • Cold compresses
   • Head elevation while sleeping
   • Hyperosmotic agents like sodium chloride 5% drops or ointment 3

Clinical Pearls and Pitfalls

• Periorbital edema may be the initial presenting symptom of serious systemic conditions like lupus erythematosus 1, 2
• Distinguish between preseptal and orbital cellulitis, as the latter is an emergency requiring immediate intervention
• Consider medication review in cases of unexplained periorbital edema, as it can be a side effect of many medications
• Persistent unilateral periorbital edema should raise suspicion for malignancy or deep orbital pathology
• When periorbital edema is accompanied by visual changes, proptosis, or restricted eye movements, urgent ophthalmologic evaluation is warranted

Periorbital edema can range from a benign, self-limiting condition to a manifestation of sight-threatening or life-threatening disease 6. A systematic approach to diagnosis is essential for appropriate management.