What are the typical presentations of chemosis?

Clinical Presentation of Chemosis

Chemosis presents as swelling or edema of the conjunctiva due to fluid accumulation in the subconjunctival space, appearing as a gelatinous or watery bulging of the conjunctiva that may range from mild to severe. 1

Characteristic Features of Chemosis

• Conjunctival edema with a gelatinous, watery appearance of the bulbar conjunctiva 1
• May present with conjunctival injection (redness) accompanying the swelling 1, 2
• Can be localized to specific areas or diffuse throughout the conjunctiva 3
• In severe cases, the chemosis may be so pronounced that it protrudes between the eyelids, preventing complete eye closure 4
• May present with a cyst-like appearance in severe cases 4

Common Etiologies of Chemosis

Inflammatory Causes

• Viral conjunctivitis - often presents with chemosis, watery discharge, and preauricular lymphadenopathy 1
• Allergic reactions - chemosis is a hallmark sign, accompanied by itching and watery discharge 1, 2
• Bacterial conjunctivitis - may present with chemosis alongside purulent discharge 1

Systemic Conditions

• Graft-versus-host disease - can cause bilateral chemosis with conjunctival injection 1
• Thyroid eye disease - associated with chemosis, upper-eyelid laxity, and eyelid imbrication 1
• Dupilumab treatment - can cause chemosis as part of dupilumab-associated ocular surface disease 1

Traumatic/Iatrogenic Causes

• Post-blepharoplasty - common complication, especially after lower eyelid surgery 5, 6
• Medication-induced - topical medications can cause chemosis, especially with preservatives 1
• Contact lens wear - can lead to chemosis from mechanical irritation or hypersensitivity 2

Rare but Serious Causes

• Orbital cellulitis or sinusitis complications - can present with severe chemosis 4
• Metastatic disease - rare cases of breast cancer metastasis presenting as chemosis have been reported 7
• Venous or lymphatic obstruction - can lead to chronic localized conjunctival chemosis 3

Associated Clinical Findings

• Discharge - the type of discharge helps differentiate the underlying cause:

  • Watery discharge suggests viral or allergic etiology 1
  • Purulent discharge suggests bacterial infection 1
  • Mucoid discharge may indicate allergic conjunctivitis 1

• Other ocular signs:

  • Follicular or papillary conjunctival reaction often accompanies chemosis in infectious or allergic cases 1, 2
  • Preauricular lymphadenopathy suggests viral etiology 1
  • Eyelid edema may be present, especially in allergic or infectious cases 1

• Duration and pattern:

  • Acute chemosis typically resolves within days to weeks 1
  • Chronic chemosis (>6 months) suggests structural alterations of conjunctival lymphatics 3
  • Post-surgical chemosis may persist for weeks after blepharoplasty 5

Distinguishing Features from Other Conditions

• Chemosis is a sign rather than a diagnosis itself, indicating fluid accumulation in the conjunctiva 2
• Unlike simple conjunctival hyperemia (redness), chemosis involves actual swelling of the tissue 2
• In conjunctivitis, chemosis is accompanied by additional inflammatory signs such as discharge, follicles, or papillary reactions 2

Clinical Pearls and Pitfalls

• Chemosis that persists beyond expected timeframes warrants further investigation for underlying systemic conditions 3
• Severe, sudden-onset chemosis with orbital signs may indicate serious conditions requiring urgent evaluation 4
• Post-surgical chemosis typically resolves with conservative management but may require intervention if persistent 5
• Conjunctival chemosis can sometimes be mistaken for other ocular surface lesions, leading to delayed diagnosis of the underlying cause 4, 7

By recognizing the characteristic appearance of chemosis and associated findings, clinicians can better determine the underlying etiology and implement appropriate management strategies.