What history should I take for a patient with periorbital swelling?

History Taking for Periorbital Swelling

When evaluating periorbital swelling, immediately focus on distinguishing between infectious, inflammatory, medication-related, traumatic, and neoplastic causes, as this determines whether you're dealing with a benign condition or a sight-threatening or life-threatening emergency. 1, 2

Temporal Characteristics

• Onset and duration: Acute onset (hours to days) suggests infection, allergy, or trauma, while gradual onset (weeks to months) points toward inflammatory conditions, thyroid disease, or neoplasm 3, 2
• Rapidity of progression: Sudden worsening suggests acute angle-closure, orbital cellulitis, or subperiosteal hematoma 3, 4
• Diurnal variation: Worse upon waking and improving throughout the day suggests endothelial dysfunction or fluid redistribution 3
• Unilateral versus bilateral: Unilateral presentation favors infection (hordeolum, preseptal/orbital cellulitis), trauma, or neoplasm; bilateral suggests systemic causes (thyroid disease, allergy, medication reaction, vasculitis) 3, 5

Associated Symptoms

Vision-Threatening Red Flags

• Visual changes: Blurred vision, diplopia, or decreased visual acuity indicate orbital involvement requiring urgent imaging 3, 4
• Eye pain: Severe pain suggests acute angle-closure, orbital cellulitis, or hordeolum 3, 5
• Proptosis or globe displacement: Indicates orbital mass effect from abscess, hematoma, or tumor 3, 4
• Impaired or painful extraocular movements: Suggests orbital cellulitis, thyroid eye disease, or subperiosteal abscess 3, 4

Infectious Symptoms

• Fever: Presence suggests orbital/preseptal cellulitis, sinusitis complications, or systemic infection 3, 2
• Purulent discharge: Points to hordeolum or bacterial conjunctivitis 3, 6
• Upper respiratory symptoms: Recent URI increases likelihood of sinusitis-related complications 3, 4
• Sinus symptoms: Headache, facial pain, or nasal congestion suggest sinusitis as underlying cause 3, 4

Inflammatory/Allergic Symptoms

• Itching: Suggests allergic etiology 3, 2
• Rhinoconjunctival symptoms: Chronic symptoms with periorbital swelling may indicate medication reaction (aspirin derivatives) 7
• Skin changes: Erythema, vesicular rash, or eyelid ulceration point to HSV or other dermatologic conditions 3

Medication History

This is critical as medication-related angioedema can mimic other serious conditions and requires specific management. 8, 7

• ACE inhibitors: Can cause angioedema even after prolonged use 8
• Aspirin and derivatives (carbasalate calcium): Rare cause of periorbital angioedema, even after years of use 7
• Topical medications: Corticosteroids (elevated IOP), chlorhexidine (endothelial toxicity), amantadine (endothelial dysfunction) 3
• Systemic medications: Sulfonamides including topiramate (ciliary body edema), anticholinergics, amiodarone, chemotherapeutic agents 3

Past Medical and Ocular History

Ocular History

• Previous episodes: Recurrent chalazia or hordeola suggest underlying blepharitis or meibomian gland dysfunction 5, 6
• Recent ocular surgery: Cataract surgery, YAG capsulotomy, or intravitreal injections increase risk of complications 3
• Contact lens wear: Type, duration, and hygiene practices 3
• Refractive error: Hyperopia increases risk of angle-closure 3
• History of chalazion excisions at same site: Raises suspicion for sebaceous carcinoma 3, 5

Systemic History

• Thyroid disease: Graves' disease, Hashimoto's thyroiditis cause thyroid eye disease 3
• Autoimmune conditions: Sarcoidosis, granulomatosis with polyangiitis, Sjögren's syndrome, IgG4-related disease 3
• Immunocompromise: HIV, immunosuppressive therapy increase infection risk 3
• Bleeding disorders or anticoagulation: Predispose to spontaneous orbital hematoma 4
• Chronic sinusitis: Can lead to orbital complications including subperiosteal hematoma 3, 4
• Malignancy history: Metastatic disease, lymphoma, or prior radiation therapy 3

Trauma History

• Blunt or penetrating injury: Recent or remote trauma to eye or periocular region 3
• Forceps delivery: Neonatal history relevant for Descemet's membrane breaks 3
• Chemical exposure: Occupational or accidental exposure 3
• Recent neurosurgery or facial surgery: Can cause postoperative swelling or complications 8

Family History

• Thyroid disease: Strong risk factor for thyroid eye disease 3
• Glaucoma or angle-closure: Family history increases risk 3
• Corneal dystrophies: Often bilateral and hereditary 3
• Genetic syndromes: Stickler syndrome, xeroderma pigmentosum 3

Social and Environmental History

• Smoking: Risk factor for thyroid eye disease 3
• UV exposure: Occupational (farming, construction) or recreational increases pterygium and ocular surface neoplasia risk 3
• Animal exposure: Increases risk of unusual infectious agents (Brucella, Borrelia) 3
• Recent travel: May expose to unusual pathogens 3
• Recent altitude changes: Sudden elevation changes can precipitate complications in patients with chronic sinusitis 4

Specific Patterns to Recognize

Preseptal vs. Orbital Cellulitis

• Preseptal: Eyelid swelling without vision changes, normal extraocular movements, no proptosis 3
• Orbital: Vision changes, painful/restricted eye movements, proptosis, requires immediate imaging and hospitalization 3

Recurrent Lesions at Same Site

• Multiple excisions at same location: Strongly suggests sebaceous carcinoma, especially in elderly patients—biopsy mandatory 3, 5

Chronic Unilateral Blepharitis

• Unresponsive to standard therapy: Warning sign for underlying carcinoma requiring further evaluation 5