What is the next best step in managing a 55-year-old female with sudden onset of periorbital (around the eye) swelling, mild pain behind the eye, and vision impairment, who has a history of seasonal allergies, sinus infections, and a previous broken nose, and has not responded to antibiotic eye drops but is experiencing nasal drainage as a side effect of prednisone (prednisone) eye drops?

Urgent Imaging with CT Scan of Sinuses and Orbits is Required

This patient requires immediate CT imaging of the sinuses and orbits to rule out orbital cellulitis, preseptal cellulitis, or acute bacterial rhinosinusitis with orbital complications, given the sudden onset of periorbital swelling, retro-orbital pain, vision changes, and failure to respond to antibiotics.

Critical Red Flags Present

This presentation contains multiple concerning features that demand urgent evaluation:

• Sudden onset within 24 hours with periorbital swelling making the eye appear smaller suggests orbital involvement beyond simple allergic disease 1
• Retro-orbital pain combined with vision changes indicates potential orbital or sinus pathology requiring immediate imaging 1
• Failure to respond to antibiotic eye drops after 5-7 days suggests this is not simple bacterial conjunctivitis 1
• History of untreated nasal fracture with recurrent sinus infections creates anatomical predisposition to complicated sinusitis 2
• Nasal drainage after starting steroid eye drops suggests communication between sinuses and ocular structures, potentially indicating sinus disease 3

Why This is NOT Simple Allergic Rhinoconjunctivitis

While the patient has risk factors for allergic disease (seasonal allergies, occupational exposure in hair salon), several features argue strongly against this diagnosis:

• Unilateral presentation - allergic rhinoconjunctivitis is characteristically bilateral 1, 4, 5
• Acute onset over one day - allergic symptoms typically develop more gradually with allergen exposure 1
• Retro-orbital pain - not a typical feature of allergic conjunctivitis, which presents with itching as the pathognomonic symptom 1, 5
• Vision impairment - allergic conjunctivitis rarely affects vision 1
• No drainage initially - allergic rhinoconjunctivitis typically presents with watery discharge and rhinorrhea 1, 4

Immediate Management Steps

1. Obtain CT Imaging Immediately

Order contrast-enhanced CT of sinuses and orbits to evaluate for:

• Orbital cellulitis or abscess
• Preseptal cellulitis
• Acute or chronic sinusitis with orbital extension
• Anatomical abnormalities from previous nasal fracture 2

2. Stop Steroid Eye Drops Temporarily

Discontinue prednisone eye drops until infection is ruled out - the FDA label explicitly warns that "acute purulent infections of the eye may be masked or activity enhanced by the presence of corticosteroid medication" and "use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections" 3. The nasal drainage after starting steroids may indicate unmasking of underlying sinus infection.

3. Urgent Ophthalmology Consultation

Refer immediately for slit-lamp examination to assess for:

• Corneal involvement
• Anterior chamber inflammation
• Intraocular pressure (steroids can cause glaucoma even after brief use) 3
• Proptosis or limitation of extraocular movements suggesting orbital involvement 1

4. Consider ENT Consultation

Given the history of untreated nasal fracture and recurrent sinus infections, ENT evaluation is warranted for assessment of:

• Chronic rhinosinusitis complications 1, 2
• Anatomical obstruction requiring surgical correction 2
• Nasal polyposis (common with chronic sinusitis) 1, 2

If Imaging Rules Out Serious Pathology

Only after excluding orbital cellulitis, abscess, and complicated sinusitis should you consider other diagnoses:

Possible Alternative: Acute Bacterial Rhinosinusitis

If CT shows acute sinusitis without orbital complications:

• Start appropriate antibiotic (amoxicillin or amoxicillin-clavulanate) for 10-14 days 2
• Add intranasal corticosteroid (fluticasone, mometasone, or budesonide) to promote drainage 6, 2
• Oral decongestants and nasal saline irrigation 2
• Do NOT restart ophthalmic steroids until infection cleared 3

Less Likely: Severe Allergic Exacerbation

Only if imaging completely normal and infection definitively ruled out:

• Intranasal corticosteroid as first-line therapy 4, 6
• Second-generation oral antihistamine (cetirizine, fexofenadine, loratadine) 4
• Intranasal antihistamine (azelastine or olopatadine) can address both nasal and ocular symptoms 1, 4
• Allergen avoidance measures for occupational exposures 1, 7

Critical Pitfalls to Avoid

• Never assume this is "just allergies" with unilateral presentation and vision changes 1
• Never continue steroid eye drops without ruling out infection - this violates FDA warnings and can lead to devastating complications including corneal perforation 3
• Never delay imaging when orbital involvement is suspected - orbital cellulitis can progress to cavernous sinus thrombosis, meningitis, or blindness 1
• Never ignore the history of untreated nasal fracture - this creates chronic anatomical obstruction predisposing to recurrent complicated sinusitis 2

Consultation Indications

The American Academy of Allergy, Asthma & Immunology guidelines recommend allergist consultation when patients have complications of rhinitis such as sinusitis, when symptoms interfere with function, or when treatment is ineffective 1. However, this patient needs urgent imaging and specialist evaluation BEFORE considering routine allergy referral given the acute presentation with vision changes and orbital signs.