What is the management for a patient with facial edema and bilateral periorbital edema a few weeks post-operative from a dilation and curettage (D&C) procedure?

Facial and Bilateral Periorbital Edema Post-D&C: Urgent Evaluation Required

This presentation is highly unusual and concerning—facial edema with bilateral periorbital swelling weeks after a D&C procedure is not a typical post-operative complication and requires immediate systematic evaluation to exclude serious systemic, allergic, or infectious etiologies. 1

Immediate Assessment Priority

You must urgently evaluate for life-threatening or sight-threatening conditions:

• Check visual acuity and intraocular pressure immediately to assess for orbital cellulitis, preseptal cellulitis, or other ocular involvement that could threaten vision 1
• Examine for signs of serious infection, including fever, warmth, erythema, pain with eye movement, proptosis, or ophthalmoplegia 1
• Review all medications initiated post-operatively, as medication-related angioedema or systemic allergic reactions are important causes of bilateral periorbital swelling after surgery 1

Differential Diagnosis Framework

The bilateral and facial distribution occurring weeks post-operatively suggests several key possibilities:

Medication-Related Causes

• Angioedema from new medications (antibiotics, NSAIDs, or other post-operative medications) is a critical consideration with bilateral periorbital involvement 1
• Review timing of symptom onset relative to any new drug exposures 2

Infectious Etiologies

• Preseptal or orbital cellulitis must be excluded given the potential for vision loss and intracranial extension 1
• Sinusitis with secondary periorbital involvement 2

Inflammatory/Systemic Causes

• Systemic inflammatory conditions or autoimmune processes 2
• Thyroid eye disease (though typically not acute post-operatively) 2
• Renal dysfunction causing fluid retention 2

Allergic Reactions

• Contact dermatitis from topical agents 3
• Systemic allergic response 3

Diagnostic Workup

If no clear etiology is immediately identified, the following evaluation is essential:

• Complete blood count, comprehensive metabolic panel to assess for infection, renal dysfunction, or electrolyte abnormalities 1
• Serum tryptase testing if allergic reaction is suspected 3
• Thyroid function tests if thyroid-related edema is considered 2
• CT or MRI imaging should have a low threshold for ordering given the unusual presentation and timing—this can identify orbital cellulitis, abscess, or other structural pathology 1

Management Approach

Immediate Actions

• Ophthalmology consultation is mandatory to exclude pathology native to the eye itself and assess for vision-threatening conditions 3
• If infection is suspected, initiate broad-spectrum antibiotics immediately while awaiting culture results 1
• If angioedema is identified, discontinue the offending agent and consider antihistamines, corticosteroids, or epinephrine depending on severity 1

Close Monitoring Protocol

• Daily reassessment is necessary if no clear etiology is immediately identified 1
• Monitor for progression of swelling, development of systemic symptoms, or visual changes 1
• Maintain a low threshold for imaging and specialist consultation given this atypical presentation 1

Critical Pitfalls to Avoid

• Do not assume this is routine post-operative swelling—the bilateral periorbital distribution and timing (weeks post-op) are not consistent with typical D&C complications 1
• Do not delay ophthalmology evaluation—vision-threatening conditions require rapid intervention 1, 3
• Do not overlook medication history—new post-operative medications are a common cause of delayed allergic reactions 1, 3
• Do not dismiss the need for imaging—orbital cellulitis or abscess can present with periorbital edema and requires urgent identification 1

Additional Considerations

If allergic etiology is confirmed, allergist referral may assist in confirming diagnosis and conducting appropriate allergic testing to prevent future reactions 3. The eventual diagnosis may require exclusion of multiple etiologies through systematic evaluation 3.

This presentation demands urgent, comprehensive evaluation rather than expectant management—the unusual timing and distribution pattern warrant aggressive investigation to prevent potential morbidity 1, 2.