What treatment is recommended for periorbital edema after consuming seafood?

Treatment of Periorbital Edema After Seafood Consumption

For periorbital edema following seafood ingestion, immediately administer oral antihistamines (diphenhydramine 25-50 mg for adults) and assess for signs of anaphylaxis or angioedema requiring emergency intervention. 1, 2

Immediate Assessment and Risk Stratification

When a patient presents with puffy eyes after eating seafood, you must first determine if this represents a simple allergic reaction versus a more severe systemic response:

• Check for respiratory symptoms, throat swelling, or difficulty breathing - these indicate anaphylaxis requiring immediate epinephrine and emergency care 1
• Assess visual acuity and eye pain - seafood allergy can trigger secondary angle-closure glaucoma through ciliary body edema and anterior lens displacement, presenting with headache, nausea, vomiting, and acute vision loss 3
• Examine for generalized angioedema beyond just periorbital involvement, as this suggests more severe IgE-mediated hypersensitivity 3, 4
• Note the timing - fish allergens can be detected in serum within 10 minutes of ingestion and trigger rapid symptoms, though some reactions may be delayed 4

First-Line Pharmacologic Management

Oral antihistamines are the cornerstone of treatment for isolated periorbital edema:

• Diphenhydramine 25-50 mg (10-20 mL) orally for adults, repeated every 4-6 hours as needed, not exceeding 6 doses in 24 hours 2
• For children 6-12 years: 25 mg (10 mL) 2
• Systemic antihistamines counter the allergic reaction and reduce edema more effectively than topical treatments for this presentation 3

Ophthalmologic Considerations

If the patient reports eye pain, vision changes, or headache along with periorbital swelling:

• Measure intraocular pressure immediately - seafood allergy can cause acute angle-closure glaucoma through uveal effusion and anterior rotation of the ciliary body 3
• Perform gonioscopy if IOP is elevated to assess angle closure 3
• If angle-closure is present, initiate IOP-lowering medications (topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors) and refer urgently to ophthalmology 5, 3
• The mechanism differs from typical pupillary block - the lens-iris diaphragm shifts forward due to ciliary body swelling from the allergic reaction 3

Monitoring and Follow-Up

• Observe for at least 4-6 hours after initial treatment, as biphasic reactions can occur 1
• Educate the patient that seafood allergens (particularly tropomyosin in crustaceans and parvalbumin in fish) can cause sensitization through both ingestion and inhalation of airborne particles during cooking 4
• Prescribe an epinephrine auto-injector for future use if the reaction involved more than isolated mild periorbital edema, as seafood allergy carries significant risk of anaphylaxis 4
• Consider allergy testing to identify specific seafood triggers, as cross-reactivity between crustaceans and mollusks is common but not universal 4

Critical Pitfalls to Avoid

• Do not dismiss eye pain or vision changes as simply part of the allergic reaction - acute angle-closure glaucoma secondary to seafood allergy is a documented complication requiring immediate ophthalmologic intervention 3
• Do not assume all seafood allergies are the same - patients may be sensitized to specific species (salt-water versus fresh-water prawns, specific fish types) and tolerate others 4
• Do not rely solely on topical treatments - periorbital edema from systemic allergic reactions requires systemic antihistamine therapy 1, 3
• ACE inhibitor use can complicate the picture - if the patient is on ACE inhibitors, angioedema can persist for at least 6 weeks after discontinuation and may be misattributed to seafood 1

When to Refer or Escalate Care

• Immediate emergency referral for any respiratory distress, throat swelling, hypotension, or signs of anaphylaxis 1
• Urgent ophthalmology referral for elevated IOP, moderate to severe eye pain, or acute vision loss 3
• Allergy/immunology referral for recurrent episodes, severe reactions, or when multiple food allergies are suspected 4