What is the role of intramuscular (IM) or oral steroids in treating periorbital redness and puffiness?

Role of IM or Oral Steroids in Periorbital Redness and Puffiness

Intramuscular steroids should not be used for periorbital redness and puffiness, while oral steroids may be considered only for severe allergic conjunctivitis with marked chemosis or lid swelling that is unresponsive to topical therapy, limited to a brief 1-2 week course. 1, 2

Intramuscular Steroids: Strong Recommendation Against Use

IM glucocorticosteroids are strongly contraindicated for allergic rhinitis and related allergic conditions affecting the periorbital area. 1

• The ARIA guidelines explicitly state that clinicians should not administer intramuscular glucocorticosteroids for allergic rhinitis, as possible side effects may be far more serious than the condition being treated 1
• This recommendation prioritizes avoiding serious complications including behavioral changes, weight gain, adrenal suppression, and rare but severe events like avascular necrosis of the femoral head 3
• A 2023 randomized controlled trial found only limited beneficial effects when systemic steroids were added to standard care for seasonal allergic rhinitis, with no significant improvement in quality of life measures 4
• The risk-benefit ratio strongly favors avoiding IM steroids given the self-limited nature of most periorbital allergic symptoms 1, 4

Oral Steroids: Limited Role in Severe Cases Only

When to Consider Oral Steroids

Oral corticosteroids may be appropriate only for severe allergic conjunctivitis with marked chemosis, significant lid swelling, or membranous conjunctivitis that has failed topical therapy. 1, 2

• The American Academy of Ophthalmology recommends topical corticosteroids as first-line steroid therapy for severe allergic conjunctivitis, reserving systemic steroids for truly refractory cases 1, 2
• For adenoviral keratoconjunctivitis with marked chemosis or lid swelling, topical corticosteroids are helpful to reduce symptoms and may reduce scarring 1
• Oral steroids should be limited to a short course of 1-2 weeks maximum when used 2

Critical Monitoring Requirements

When oral steroids are prescribed for periorbital conditions:

• Baseline and periodic intraocular pressure (IOP) measurement is mandatory 2
• Pupillary dilation to evaluate for glaucoma and cataract formation must be performed 2
• Close follow-up within 1 week is warranted for patients with severe disease 1

Preferred Treatment Algorithm for Periorbital Redness and Puffiness

First-Line Approach (Allergic Etiology)

• Dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) are the most effective first-line treatment for allergic causes 2
• Cold compresses and refrigerated preservative-free artificial tears to dilute allergens 2
• Allergen avoidance strategies including sunglasses as a barrier 2

Second-Line Approach (Inadequate Response)

• Add topical corticosteroids with low side-effect profile (loteprednol etabonate) for 1-2 weeks only 2
• This is preferred over systemic steroids due to lower risk of systemic side effects 1, 2

Third-Line Approach (Severe or Refractory Cases)

• Topical cyclosporine 0.05% or tacrolimus for cases unresponsive to topical steroids 2
• Consider supratarsal injection of corticosteroid for severe atopic keratoconjunctivitis 2
• Oral steroids only as a last resort for truly severe cases with marked chemosis or membranous conjunctivitis 1, 2

Common Pitfalls to Avoid

• Never use IM steroids for periorbital allergic conditions—the risks far outweigh any potential benefits 1
• Avoid prolonged topical corticosteroid use beyond 2 weeks without close monitoring, as this increases risk of elevated IOP and cataract formation 1, 2
• Do not prescribe oral antihistamines as primary treatment for allergic conjunctivitis, as they may worsen dry eye syndrome 2
• Avoid punctal plugs in allergic conjunctivitis, as they prevent flushing of allergens from the ocular surface 2
• Do not use chronic vasoconstrictors, which can cause rebound hyperemia (conjunctivitis medicamentosa) 2

Special Considerations for Specific Etiologies

Periorbital Edema from TKI Therapy (Imatinib)

• Diuretic therapy has limited benefit for imatinib-induced periorbital edema 1
• Changing to an alternative TKI may be necessary but is rarely appropriate 1
• Topical steroids have limited efficacy for this drug-induced etiology 1

Infantile Hemangiomas

• Propranolol has become the mainstay of systemic therapy for periocular hemangiomas 1
• Intralesional steroids were previously used but are now avoided due to risk of central retinal artery embolism, hypopigmentation, fat atrophy, and eyelid necrosis 1
• Topical timolol is effective for superficial periocular hemangiomas without the risks of systemic or intralesional steroids 1